Rethinking Patient Safety

209 Pages·2017·1.245 MB·English

by  WOODWARD, SUZETTE

Rethinking
Patient Safety

Rethinking
Patient Safety
By Suzette Woodward
CRC Press
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Library of Congress Cataloging‑ in‑ Publication Data
Names: Woodward, Suzette, author.
Title: Rethinking patient safety / Suzette Woodward.
Description: Boca Raton : Taylor & Francis, 2017. | Includes bibliographical
references.
Identifiers: LCCN 2016044132| ISBN 9781498778541 (hardback : alk. paper) |
ISBN 9781498778558 (ebook)
Subjects: LCSH: Medical errors--Prevention. | Medical care--Quality control.
| Patients--Safety measures.
Classification: LCC R729.8 .W66 2017 | DDC 610.28/9--dc23
LC record available at https://lccn.loc.gov/2016044132
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When you talk, you are only repeating what you already
know. But if you listen, you may learn something new.
Dalai Lama

Contents
Preface ..................................................................................xi
Acknowledgements ...........................................................xiii
Introduction .......................................................................xv
Author ................................................................................xxi
1 Patient Safety ...........................................................1
What Is Patient Safety? ........................................................1
Pioneers ...............................................................................3
Over One Hundred Years Later ..........................................7
Suggested Reading .............................................................10
2 The Scale of the Problem .......................................11
Suggested Reading .............................................................19
3 A Culture of Learning ............................................21
Are We Learning from Harm? ...........................................21
Learning the Johns Hopkins Way .....................................22
Impact on Patients and Their Families: Sam’ s Story ........25
Failing to Learn: My Own Story ........................................29
Suggested Reading .............................................................33
4 Systems Approach to Safety ..................................35
Understanding the Basics of a Safer System .....................35
Learning from Other High-Risk Industries .......................37
Resilience ............................................................................38
Safety I and Safety II ..........................................................39
vii
viii ◾ Contents
Standardisation ...................................................................40
Human Factors ...................................................................41
Shifting from ‘ One Size Fits All’ to an Intelligent
Approach to Risk ...............................................................43
Suggested Reading ............................................................44
5 The Right Culture for Safety .................................45
The Just Culture .................................................................45
Human Error ......................................................................49
Risky Behaviour .................................................................50
Reckless Behaviour ............................................................52
Suggested Reading .............................................................54
6 Learning or Counting from Incidents ....................55
Incident Reporting .............................................................55
Learning from Incident Reporting .....................................59
Performance Management .................................................62
Quality of Reports .............................................................64
The Truth...........................................................................64
What Can Be Done Differently for Incident Reporting? ...65
7 Relegated to the Back Office .................................69
Risk Management and Incident Investigation ...................69
Incident Investigation .........................................................71
Suggested Reading .............................................................74
8 The Impact on Front‑Line Workers ........................75
Reflective Observation .......................................................75
Bob’ s Story ........................................................................77
Kimberley’ s Story ...............................................................79
Richie’ s Story ......................................................................82
Suggested Reading .............................................................87
9 The Implementation Challenge ..............................89
Just Do It ............................................................................89
Seven Steps.........................................................................92
Vincristine Error .................................................................93
To Checklist or Not to Checklist........................................97
Suggested Reading ...........................................................100
Contents ◾ ix
10 Implementation: The Way Forward .....................101
What Can We Do Differently for Implementation? .........101
Factors That Hinder and Help .........................................103
Suggested Reading ...........................................................107
11 The Next Fifteen Years and Beyond ....................109
Not Alone .........................................................................109
How Did We Get Here? ...................................................116
12 Sign Up to Safety .................................................119
Creating a New Movement ..............................................119
What Have We Learnt So Far? .........................................126
13 Enlightenment .....................................................131
Profound Simplicity ..........................................................131
Our Throughline ..............................................................133
Our Solution for Change Is Conversations ..................133
14 An Evolving Concept ............................................139
Good Conversations .........................................................139
A Variety of Methodologies: The World Café Story ........141
Methods Used to Date for Patient Safety Conversations ....145
Factors That Hinder a Good Conversation .....................147
Suggested Reading ...........................................................152
15 Facilitated Conversations .....................................153
Facilitated Conversations to Narrow the
Implementation Gap ........................................................153
Trio Methodology .............................................................154
Quad Methodology ..........................................................159
Fishbowl Methodology ....................................................159
Small Group Conversations .............................................161
Large Group Conversations .............................................161
What We Have Learnt ......................................................163
Conclusion ..................................................................167
References and Further Reading ................................171
Index ..........................................................................181