LEADER 05490nam 2200685Ia 450 001 9910452574803321 005 20200520144314.0 010 $a0-19-176856-1 010 $a1-283-58109-4 010 $a9786613893543 010 $a0-19-157540-2 035 $a(CKB)2550000000105519 035 $a(EBL)975662 035 $a(OCoLC)801363490 035 $a(SSID)ssj0000692443 035 $a(PQKBManifestationID)11403383 035 $a(PQKBTitleCode)TC0000692443 035 $a(PQKBWorkID)10639158 035 $a(PQKB)11675835 035 $a(StDuBDS)EDZ0000128757 035 $a(MiAaPQ)EBC975662 035 $a(Au-PeEL)EBL975662 035 $a(CaPaEBR)ebr10581650 035 $a(CaONFJC)MIL389354 035 $a(EXLCZ)992550000000105519 100 $a20090817d2009 uy 0 101 0 $aeng 135 $aur|n|---||||| 181 $ctxt 182 $cc 183 $acr 200 10$aPractical patient safety$b[electronic resource] /$fby John Reynard, John Reynolds, Peter Stevenson 210 $aOxford ;$aNew York $cOxford University Press$d2009 215 $a1 online resource (319 p.) 300 $aDescription based upon print version of record. 311 $a0-19-923993-2 320 $aIncludes bibliographical references and index. 327 $aPreface; Acknowledgements; Contents; 1 Clinical error: the scale of the problem; The Harvard Medical Practice Study 1984; The Quality in Australian Healthcare Study 1992; The University College London Study 2001; Danish, New Zealand, Canadian, and French studies; The frequency and costs of adverse drug events; Accuracy of retrospective studies; Error rates revealed in retrospective studies are of the same order of magnitude as those found in observational studies; Error rates according to type of clinical activity; Deaths from adverse events; Extra bed days as a consequence of error 327 $aCriminal prosecutions for medical errorsReliability: other industries; Reliability: healthcare; References; 2 Clinical errors:What are they?; Sources of error in primary care and office practice; Sources of error along the patient pathway in hospital care and potential methods of error prevention; Errors in dealing with referral letters; Errors of identification; Errors in note keeping; Errors with medical records in general; Other slips in letters that you have dictated; Errors as a consequence of patients failing to attend appointments for investigations or for outpatient consultations 327 $aWashing your hands between patients and attention to infection controlAdmission to hospital; Diagnostic errors in general; Errors in drug prescribing and administration; Reducing errors in blood transfusion; Intravenous drug administration; Errors in the operating theatre; The use of diathermy; Harm related to patient positioning; Leg supports that give way; Generic safety checks prior to any surgical procedure; Failure to give DVT prophylaxis; Failure to give antibiotic prophylaxis; Errors in the postoperative period; Shared care; Medical devices; References 327 $a3 Safety culture in high reliability organizationsHigh reliability organizations: background; High reliability organizations: common features; The consequences of failure; 'Convergent evolution' and its implication for healthcare; Learning from accidents: overview of basic high reliability organizational culture; Elements of the safety culture; Counter-intuitive aspects of high reliability organization safety culture; References; 4 Case studies; Case study 1: wrong patient; Case study 2: wrong blood; Case study 3: wrong side nephrectomy; Case study 4: another wrong side nephrectomy 327 $aCase study 5: yet another wrong side nephrectomy caseCase study 6: medication error-wrong route (intrathecal vincristine); Case study 7: another medication error-wrong route (intrathecal vincristine); Case study 8: medication error-wrong route (intrathecal vincristine); Case study 9: medication error-miscalculation of dose; Case study 10: medication error-frequency of administration mis-prescribed as 'daily' instead of 'weekly'; Case study 11: medication error-wrong drug; Case study 12: miscommunication of path lab result; Case study 13: biopsy results for two patients mixed up 327 $aCase study 14: penicillin allergy death 330 $aFollowing recent high profile cases of surgical error in the UK and USA, patient safety has become a key issue in healthcare, now placed at heart of junior doctor's training. Errors made by doctors are very similar to those made in other high risk organisations, such as aviation, nuclear and petrochemical industries. Practical Patient Safety aims to demonstrate how core principles of safety from these industries can be applied in surgical and medical practice, in particular through training for health care professionals and healthcare managers.Whilst theoretical aspects of risk management form 606 $aMedical errors$xPrevention 606 $aPatients$xSafety measures 608 $aElectronic books. 615 0$aMedical errors$xPrevention. 615 0$aPatients$xSafety measures. 676 $a610.289 700 $aReynard$b John$0898746 701 $aReynolds$b John$cDr.$0898747 701 $aStevenson$b Peter$0898748 801 0$bMiAaPQ 801 1$bMiAaPQ 801 2$bMiAaPQ 906 $aBOOK 912 $a9910452574803321 996 $aPractical patient safety$92007908 997 $aUNINA