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
Compare Your Performance to Others
Should "Zero Errors" be Your Goal?
PART 3: PATIENT SAFE PROCESSES
Identify Error Potential and Consequences
Failure Mode and Effect 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