This book offers step-by-step instructions for designing and implementing an effective proactive patient safety management initiative. Topics include: measuring important elements of patient safety; how to identify the error-producing factors in high-risk patient care processes; using comparative data to establish improvement opportunities; techniques for error-proofing health care services to prevent adverse events; why root cause analysis of sentinel events won't prevent future patients from being harmed by mistakes; and how to create a patient-safe work culture.This book will help health care organizations meet the new Joint Commission requirements for proactive risk reduction activities.

Table of Contents

PART 1: PATIENT SAFETY IN HEALTH CARE

You Be the Judge

Avoid the Traps

What's Taken Health Care So Long?

Patient Safety Culture Survey

What Needs to Be Done

PART 2: PATIENT SAFETY INFORMATION

Measures of Patient Safety

Is Your "Early Warning System" Effective?

What is a High-Risk Process?

Select the High Risk Processes in Your Organization

Identify Critical Human Actions to Measure

Measures of Critical Human Actions

Identifying Unsafe Issues in the Work Environment

Patient Safety Measurement Inventory

Collecting Patient Safety Measurement Data

Patient Incident Data: How Much is Enough?

How Large is Your Under-Reporting Problem?

How to Obtain Better Reporting of Patient Incidents

Incident Reports are Not Enough

The Optimal Patient Safety Information System

Reporting Patient Safety Measurement Data

Graphic Data Display

Critical Human Action Reports

How to Respond to Measurement Results

Compare Performance to Pre-Defined Thresholds

Analyze Patterns and Trends of Performance

Control Charts

Compare Your Performance to Others

Should "Zero Errors" be Your Goal?

PART 3: PATIENT SAFE PROCESSES

Identify Error Potential and Consequences

Checklist Analysis

What-If Analysis

Failure Mode and Effect Analysis

Barrier Analysis

Critical Human Action Profile

Human Compliance Analysis

Could This Happen Here?

Select Process Redesign Solutions

Sources for Process Redesign Ideas

A Quick Overview: How to Design a Safer Patient Care Process

Just Do It!

PART 4: SAFETY PROGRAM COMPONENTS

Essential Elements in a Patient Safety Program