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Practical patient safety [[electronic resource] /] / by John Reynard, John Reynolds, Peter Stevenson
| Practical patient safety [[electronic resource] /] / by John Reynard, John Reynolds, Peter Stevenson |
| Autore | Reynard John |
| Pubbl/distr/stampa | Oxford ; ; New York, : Oxford University Press, 2009 |
| Descrizione fisica | 1 online resource (319 p.) |
| Disciplina | 610.289 |
| Altri autori (Persone) |
ReynoldsJohn, Dr.
StevensonPeter |
| Soggetto topico |
Medical errors - Prevention
Patients - Safety measures |
| Soggetto genere / forma | Electronic books. |
| ISBN |
0-19-176856-1
1-283-58109-4 9786613893543 0-19-157540-2 |
| Formato | Materiale a stampa  |
| Livello bibliografico | Monografia |
| Lingua di pubblicazione | eng |
| Nota di contenuto |
Preface; 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
Criminal 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 Washing 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 3 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 Case 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 Case study 14: penicillin allergy death |
| Record Nr. | UNINA-9910452574803321 |
Reynard John
|
||
| Oxford ; ; New York, : Oxford University Press, 2009 | ||
| Materiale a stampa | ||
| Lo trovi qui: Univ. Federico II | ||
| ||
Practical patient safety [[electronic resource] /] / by John Reynard, John Reynolds, Peter Stevenson
| Practical patient safety [[electronic resource] /] / by John Reynard, John Reynolds, Peter Stevenson |
| Autore | Reynard John |
| Pubbl/distr/stampa | Oxford ; ; New York, : Oxford University Press, 2009 |
| Descrizione fisica | xviii, 300 p. : ill |
| Altri autori (Persone) |
ReynoldsJohn, Dr.
StevensonPeter |
| Soggetto topico |
Medical errors - Prevention
Patients - Safety measures |
| ISBN |
0-19-157540-2
1-283-58109-4 0-19-176856-1 9786613893543 |
| Formato | Materiale a stampa |
| Livello bibliografico | Monografia |
| Lingua di pubblicazione | eng |
| Record Nr. | UNINA-9910795730003321 |
|
Reynard John
|
||
| Oxford ; ; New York, : Oxford University Press, 2009 | ||
| Materiale a stampa | ||
| Lo trovi qui: Univ. Federico II | ||
| ||
Practical patient safety / / by John Reynard, John Reynolds, Peter Stevenson
| Practical patient safety / / by John Reynard, John Reynolds, Peter Stevenson |
| Autore | Reynard John |
| Edizione | [1st ed.] |
| Pubbl/distr/stampa | Oxford ; ; New York, : Oxford University Press, 2009 |
| Descrizione fisica | xviii, 300 p. : ill |
| Disciplina | 610.289 |
| Altri autori (Persone) |
ReynoldsJohn, Dr.
StevensonPeter |
| Soggetto topico |
Medical errors - Prevention
Patients - Safety measures |
| ISBN |
0-19-157540-2
1-283-58109-4 0-19-176856-1 9786613893543 |
| Formato | Materiale a stampa |
| Livello bibliografico | Monografia |
| Lingua di pubblicazione | eng |
| Nota di contenuto |
Intro -- Contents -- Preface -- Acknowledgements -- 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 -- Criminal prosecutions for medical errors -- Reliability: 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 -- Washing your hands between patients and attention to infection control -- Admission 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.
3 Safety culture in high reliability organizations -- High 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 -- Case study 5: yet another wrong side nephrectomy case -- Case 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 -- Case study 14: penicillin allergy death -- Case study 15: missing X-ray report -- Case study 16: medication not given -- Case study 17: oesophageal intubation -- Case study 18: tiredness error -- Case study 19: inadequate training -- Case study 20: patient fatality-anaesthetist fell asleep -- References -- 5 Error management -- How accidents happen: the person approach versus the systems approach -- Error chains -- System failures -- 'Catalyst events' -- Human error -- Error classification -- How experts and novices solve problems -- Three error management opportunities -- Detecting and reversing incipient adverse events in real time: 'Red flags'. Red flags: the symptoms and signs of evolving error chains -- Speaking up protocols -- Error management using accident and incident data -- References -- 6 Communication failure -- The prevalence of communication failures in adverse events in healthcare -- Communication failure categories -- Whose fault: message sender or receiver? -- Safety-critical communications (SCC) protocols -- How to prevent communication errors in specific healthcare situations -- Composing an 'abnormal' (non-routine) safety-critical message -- Written communication/documentation communication failures -- References -- 7 Situation awareness -- Situation awareness: definitions -- Three levels of situation awareness -- Catastrophic loss of situation awareness and the associated syndrome: 'mind lock' -- Understanding loss of situation awareness -- Cognitive failures: the role of mental models/the psychology of mistakes -- Mental models: the problems -- Ensuring high situation awareness -- Two special cases involving loss of situation awareness -- References -- 8 Professional culture -- Similarities between two professions -- Negative aspects of professional cultures -- Steep hierarchy -- Changing the pilots' professional culture -- Team resource management/non-technical skills -- References -- 9 When carers deliberately cause harm -- References -- 10 Patient safety toolbox -- Practical ways to enhance the safety of your patients -- 11 Conclusions -- Glossary -- A -- B -- C -- E -- F -- H -- I -- L -- M -- N -- O -- P -- R -- S -- T -- U -- W -- Appendices -- Appendix 1: Initiating a safety-critical (verbal) communication (STAR) -- Appendix 2: I-SBAR-to describe a (deteriorating) patient's condition -- Appendix 3: General patient safety tools -- Appendix 4: Red flags (the symptoms and signs of an impending error) -- Index -- A -- B -- C -- D -- E -- F -- G -- H -- I -- J -- K. L -- M -- N -- O -- P -- Q -- R -- S -- T -- U -- V -- W. |
| Record Nr. | UNINA-9910822891203321 |
|
Reynard John
|
||
| Oxford ; ; New York, : Oxford University Press, 2009 | ||
| Materiale a stampa | ||
| Lo trovi qui: Univ. Federico II | ||
| ||