What Every Health Care Organization Should Know About Sentinel Events

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Patient Safety and Quality

Author : Ronda Hughes
Publisher : Department of Health and Human Services
Page : 592 pages
File Size : 45,8 Mb
Release : 2008
Category : Medical
ISBN : IOWA:31858055672798

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Patient Safety and Quality by Ronda Hughes Pdf

"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/

Advances in Patient Safety

Author : Kerm Henriksen
Publisher : Unknown
Page : 526 pages
File Size : 53,9 Mb
Release : 2005
Category : Medical
ISBN : CHI:70548902

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Advances in Patient Safety by Kerm Henriksen Pdf

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.

Keeping Patients Safe

Author : Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety
Publisher : National Academies Press
Page : 485 pages
File Size : 47,7 Mb
Release : 2004-03-27
Category : Medical
ISBN : 9780309187367

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Keeping Patients Safe by Institute of Medicine,Board on Health Care Services,Committee on the Work Environment for Nurses and Patient Safety Pdf

Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

Biennial Review of Health Care Management

Author : Grant T. Savage,Myron D. Fottler
Publisher : Emerald Group Publishing
Page : 248 pages
File Size : 52,7 Mb
Release : 2009-08-07
Category : Medical
ISBN : 9781848556737

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Biennial Review of Health Care Management by Grant T. Savage,Myron D. Fottler Pdf

Features reviews of health care management, linking concerns about health care workforce management with health care organization management issues. This book focuses on health care workforce management issues, including allied health professionals, nurses, and physicians, and on health care organization management issues.

Front Line of Defense

Author : Joint Commission Resources, Inc
Publisher : Unknown
Page : 184 pages
File Size : 52,6 Mb
Release : 2007
Category : Accidents
ISBN : UOM:39015060803007

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Front Line of Defense by Joint Commission Resources, Inc Pdf

Includes examples of adverse events, medical errors, and 'near misses' within a variety of health care settings to help you identify possible root causes of adverse events and medical errors and strategies nurses can use to prevent adverse events. This title helps to create a safer, more efficient environment.

Root Cause Analysis and Improvement in the Healthcare Sector

Author : Bjørn Andersen,Marti Beltz
Publisher : Quality Press
Page : 257 pages
File Size : 48,6 Mb
Release : 2009-11-09
Category : Business & Economics
ISBN : 9780873891257

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Root Cause Analysis and Improvement in the Healthcare Sector by Bjørn Andersen,Marti Beltz Pdf

Healthcare organizations and professionals have long needed a straightforward workbook to facilitate the process of root cause analysis (RCA). While other industries employ the RCA tools liberally and train facilitators thoroughly, healthcare has lagged in establishing and resourcing a quality culture. Presently, a growing number of third-party stakeholders are holding access to accreditation and reimbursement pending demonstration of a full response to events outside of expected practice. An increasing number of exceptions to healthcare practice have precipitated a strong response advocating the use of proven quality tools in the industry. In addition, the industry has now expanded its scope beyond the hospital walls to many ancillary healthcare facilities with little experience in implementing quality tools. This book responds to the demand for a RCA workbook written specifically for healthcare, yet still broad in its definition of the industry. This book contains everything that the typical RCA leader in healthcare requires: A text specific to healthcare, but using the broadest definition of the industry to include not only acute care hospitals, but rehabilitation facilities, long-term care facilities, outpatient surgery centers, ambulatory services, and general office practices. A workbook-style format that walks through the process, step-by-step. Straightforward text without “sidebars,” “tables,” and “tips.” Worksheets are provided at the end of the book to reduce reader distraction within the text. A wide range of real-world examples. Format for use by the most naive of users and most basic of processes, as well as a separate section for more advanced users or more complex issues. Templates, both print and electronic, included for the reader’s use. Ready-to-use educational materials with scripting to enable the user to train others and garner support for the use of the techniques. Background text for users in leadership to understand the tools in the larger context of healthcare improvement. Up-to-date information on the latest in the use of RCA in satisfying mandatory reporting requirements and slaying the myth that the process is onerous and fraught with barriers. Background text and tools/process are separated to facilitate the readers’ specific needs. Healthcare leaders can appreciate the current context and requirements without wading through the actual techniques; end-users can begin learning the skills without wading through dense administrative text. Language and tone promoting the use of the tools for improvement of processes that have experienced exceptions, as opposed to assigning blame for errors. Attention to process ownership, training, and resourcing. And, most importantly, thorough description of the improvement process as well as the analysis.

The Value of Close Calls in Improving Patient Safety

Author : Joint Commission Resources, Inc
Publisher : Joint Commission Resources
Page : 206 pages
File Size : 52,9 Mb
Release : 2011
Category : Health & Fitness
ISBN : 9781599404158

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The Value of Close Calls in Improving Patient Safety by Joint Commission Resources, Inc Pdf

Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems

Alexander's Care of the Patient in Surgery - E-Book

Author : Jane C. Rothrock
Publisher : Elsevier Health Sciences
Page : 1330 pages
File Size : 51,8 Mb
Release : 2010-06-09
Category : Medical
ISBN : 9780323189057

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Alexander's Care of the Patient in Surgery - E-Book by Jane C. Rothrock Pdf

For more than 65 years, Alexander's Care of the Patient in Surgery has been a trusted source for detailed information on perioperative nursing. Well-known author and educator Jane C. Rothrock sets up a solid foundation for practice, and offers step-by-step instructions for over 400 surgical interventions as well as many minimally invasive surgical procedures, all backed by the latest research. More than 1,000 full-color illustrations and photos depict procedures and methods, as well as surgical anatomy and instrumentation. This edition adds Rapid Response Team boxes with suggested interventions, plus coverage of new trends in patient and staff safety, the increase in interventional radiology, and the growth of outpatient ambulatory surgery. Alexander's gives you the tools you need to provide safe, cost-effective, high-quality patient care.

To Err Is Human

Author : Institute of Medicine,Committee on Quality of Health Care in America
Publisher : National Academies Press
Page : 312 pages
File Size : 47,9 Mb
Release : 2000-03-01
Category : Medical
ISBN : 9780309068376

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To Err Is Human by Institute of Medicine,Committee on Quality of Health Care in America Pdf

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Alexander's Surgical Procedures - E-Book

Author : Jane C. Rothrock,Sherri Alexander
Publisher : Elsevier Health Sciences
Page : 944 pages
File Size : 41,8 Mb
Release : 2014-09-05
Category : Medical
ISBN : 9780323292702

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Alexander's Surgical Procedures - E-Book by Jane C. Rothrock,Sherri Alexander Pdf

Developed specifically for surgical technologists, Alexander's Surgical Procedures provides proven, step-by-step coverage of essential surgical procedures from one of the most trusted sources in surgical technology. Building on the renowned content of Alexander's Care of the Surgical Patient, 14th Edition, respected authorities Jane Rothrock and Sherri Alexander (AST president 2007 - 2011) guide you through the pre-op set up, procedure pathology/steps, and post-op considerations for all required procedures. This approachable, easy-to-use resource complements the fundamental coverage in your other surgical technology textbooks, and detailed procedure videos on a companion Evolve website help you ensure success from the classroom to the OR. Content adapted from Alexander's Care of the Surgical Patient, 14th Edition provides comprehensive procedural coverage optimized for your specific needs as a surgical technologist. Surgical Technologist Considerations boxes detail practical strategies for applying chapter content to specialty procedures. Complete pre-op set up, draping, and other instructions for each procedure equip you to confidently perform all of the duties of surgical technologist in the OR setting. Chapter Outlines, Learning Objectives, and Chapter Summaries help you study chapter content more effectively. Review questions in the text and case studies on Evolve reinforce key concepts and encourage critical thinking. OR Live links on Evolve direct you to step-by-step procedure videos for commonly performed procedures. More than 700 full-color illustrations clarify surgical anatomy, instrumentation, procedures, and methods. Surgical Pharmacology tables provide quick, convenient access to generic/trade names, purpose/description, and pharmacokinetics for drugs most commonly associated with each specific surgical procedure. Cutting-edge content reflects the latest interventions and patient care techniques in surgical practice. Geriatric Consideration boxes help you manage surgical challenges unique to geriatric patients. Patient Safety boxes alert you to recent Joint Commission safety initiatives to ensure safe performance of key tasks. History boxes present chapter content in a broader context to enhance your understanding and retention. Ambulatory Surgical Considerations boxes highlight important changes to patient care within appropriate procedures. Risk Reduction Strategies boxes provide specific steps you can take to improve patient safety.

Textbook of Patient Safety and Clinical Risk Management

Author : Liam Donaldson,Walter Ricciardi,Susan Sheridan,Riccardo Tartaglia
Publisher : Springer Nature
Page : 496 pages
File Size : 48,7 Mb
Release : 2020-12-14
Category : Medical
ISBN : 9783030594039

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Textbook of Patient Safety and Clinical Risk Management by Liam Donaldson,Walter Ricciardi,Susan Sheridan,Riccardo Tartaglia Pdf

Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.

Resident Duty Hours

Author : Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety
Publisher : National Academies Press
Page : 427 pages
File Size : 42,9 Mb
Release : 2009-04-27
Category : Medical
ISBN : 9780309131520

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Resident Duty Hours by Institute of Medicine,Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety Pdf

Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Data-Guided Healthcare Decision Making

Author : Ramalingam Shanmugam
Publisher : Cambridge University Press
Page : 529 pages
File Size : 50,5 Mb
Release : 2023-05-31
Category : Medical
ISBN : 9781009212014

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Data-Guided Healthcare Decision Making by Ramalingam Shanmugam Pdf

This book effectively exposes and illustrates the ideas and tools for optimal healthcare decisions taken from evidence.