Prevention is better than cure : learning from adverse events in healthcare

137 Pages·2017·2.92 MB·English

by  Leistikow

Prevention is Better
Than Cure
LEARNING FROM ADVERSE
EVENTS IN HEALTHCARE
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Prevention is Better
Than Cure
LEARNING FROM ADVERSE
EVENTS IN HEALTHCARE
Ian Leistikow MD, PhD
Senior Inspector
Dutch Healthcare Inspectorate
and
Researcher
Institute of Health Policy & Management
Erasmus University Rotterdam
The Netherlands
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CRC Press
Taylor & Francis Group
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© 2017 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
All Rights Reserved. Authorized translation from the Dutch language edition published by
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Version Date: 20171202
International Standard Book Number-13: 978-1-138-19776-3 (Paperback)
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Library of Congress Cataloging‑in‑Publication Data
Names: Leistikow, Ian, author.
Title: Prevention is better than cure / Ian Leistikow.
Other titles: Voorkomen is beter. English
Description: Boca Raton, FL : CRC Press, 2017.
Identifiers: LCCN 2016035053| ISBN 9781138197763 (pbk. : alk. paper) | ISBN
9781315276366 (ebook)
Subjects: | MESH: Medical Errors--prevention & control | Patient
Harm--prevention & control | Case Reports
Classification: LCC R729.8 | NLM WB 100 | DDC 610.289--dc23
LC record available at https://lccn.loc.gov/2016035053
Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com
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Contents
Preface vii
About the author ix
Abbreviations xi
Introduction xiii
1 Worst case scenario 1
2 Your own observation is flawed 7
3 Assumption is the mother of all screw-ups 13
4 Be prepared 19
5 Speak up 25
6 What am I missing here? 33
7 Nine red flags 41
8 HALT 47
9 Photo or film 53
10 Risk accumulation 61
11 A just culture 67
12 Blind faith 77
13 Bias 83
14 Professional performance 91
15 Open disclosure 99
16 Epilogue 107
17 Summary 109
References 111
Index 117
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Preface
Why do things go wrong in healthcare? Every country, every culture, has a form
of healthcare set up to protect fellow humans against discomfort, disability, dis-
ease and death. Nevertheless, this same system, in all countries and cultures, is
regularly the cause of discomfort, disability, disease and death.
Prevention is Better than Cure describes real-life cases of serious adverse
events in healthcare and reflects on the underlying causes. These are eye-open-
ers to many healthcare professionals, because most are still not trained in safety
competencies. Due to this, they are unaware how circumstances influence their
behaviour and how this behaviour can impair patient safety. Not reading a
patient’s chart, neglecting concerns raised by nursing, assuming something has
been taken care of without making sure, letting relationship issues trump safety
issues, accepting exhausting working hours, are just a few examples. A challenge
within healthcare is to engage in a dialogue about behaviour without regressing
to ‘blaming and shaming’.
Prevention is Better than Cure contributes to making unsafe behaviour some-
thing one can talk about non-judgementally. It offers healthcare professionals
concrete suggestions on how they can avoid adverse events and further improve
the quality of the care they deliver.
Ian Leistikow
vii
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About the author
Ian Leistikow is a non-practising physician. He was the coordinator of the
patient safety programme within the University Medical Centre Utrecht,
the Netherlands, from 2003 to 2011. This programme comprised, for exam-
ple, the introduction of Root Cause Analysis (RCA), proactive risk a nalysis
(HFMEA), research on handoffs, research on patient participation and a
video game on patient safety (www.airmedicsky1.org). He has set up various
patient safety-related training modules, has published multiple articles about
patient safety and is co-author of a book on RCA. In December 2011 he pub-
lished his PhD thesis on how the Board of Directors can lead patient safety
improvements. His thesis is condensed into an article that was published in
the BMJ in July 2011. In 2014 he published a Dutch book on learning from
Sentinel Events, which was widely recognised in the Netherlands. Since April
2011 Ian has worked as Senior Inspector at the Dutch Healthcare Inspectorate.
There his tasks include judging the quality of sentinel event analysis reports
from hospitals and coordinating the Dutch national set of quality indicators for
hospitals. Ian is member of the Strategic Advisory Board of the International
Forum on Quality and Safety in Healthcare. He is also one of the initiators
of GetUpGetBetter (www.getupgetbetter.com), a series of international health-
care quality competitions, that is currently being developed.
ix
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