To Do No Harm: Ensuring Patient Safety in Health Care Organizations (J-B AHA Press) PDF
Preview To Do No Harm: Ensuring Patient Safety in Health Care Organizations (J-B AHA Press)
ffirs.qxd 11/11/04 9:53 AM Page v Y TO DO NO HARM Ensuring Patient Safety in Health Care Organizations Julianne M. Morath Joanne E. Turnbull Foreword by Lucian L. Leape ffirs.qxd 11/11/04 9:53 AM Page ii ffirs.qxd 11/11/04 9:53 AM Page i ffirs.qxd 11/11/04 9:53 AM Page ii ffirs.qxd 11/11/04 9:53 AM Page iii TO DO NO HARM ffirs.qxd 11/11/04 9:53 AM Page iv ffirs.qxd 11/11/04 9:53 AM Page v Y TO DO NO HARM Ensuring Patient Safety in Health Care Organizations Julianne M. Morath Joanne E. Turnbull Foreword by Lucian L. Leape ffirs.qxd 11/11/04 9:53 AM Page vi Copyright © 2005 by John Wiley & Sons,Inc.All rights reserved. Published by Jossey-Bass A Wiley Imprint 989 Market Street,San Francisco,CA 94103-1741 www.josseybass.com No part of this publication may be reproduced,stored in a retrieval system,or transmitted in any form or by any means,electronic,mechanical,photocopying,recording,scanning,or otherwise,except as permitted under Section 107 or 108 of the 1976 United States Copyright Act,without either the prior written permission of the Publisher,or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center,Inc.,222 Rosewood Drive,Danvers,MA 01923,978-750-8400, fax 978-750-4470,or on the web at www.copyright.com.Requests to the Publisher for permission should be addressed to the Permissions Department,John Wiley & Sons,Inc.,111 River Street, Hoboken,NJ 07030,201-748-6011,fax 201-748-6008,e-mail:[email protected]. Jossey-Bass books and products are available through most bookstores.To contact Jossey-Bass directly call our Customer Care Department within the U.S.at 800-956-7739,outside the U.S.at 317-572-3986,or fax 317-572-4002. Jossey-Bass also publishes its books in a variety of electronic formats.Some content that appears in print may not be available in electronic books. The WalkRounds questions listed on p.19 are © Joint Commission Resources:Jt Comm J Qual Safe. Oakbrook Terrace,IL:Joint Commission on Accreditation of Healthcare Organizations,2003,18. Reprinted with permission. The excerpt on pp.186–187 by DonaldBerwick is copyright 1996,BMJ Publishing Group.Reprinted with permission. The excerpt on p.198 by Valerie Reitman is copyright 2003,Los Angeles Times.Reprinted with permission. Library of Congress Cataloging-in-Publication Data Morath,Julianne M. To do no harm :ensuring patient safety in health care organizations / Julianne M.Morath, Joanne E.Turnbull ;foreword by Lucian L.Leape.— 1st ed. p.;cm. Includes bibliographical references. ISBN 0-7879-6770-X (alk.paper) 1. Medical errors—Prevention. 2. Health facilities. [DNLM:1. Medical Errors—prevention & control. 2. Safety Management—organization & administration. 3. Health Facilities—organization & administration. 4. Organizational Innovation. 5. Truth Disclosure. WX 185 M831t 2004] I. Turnbull, Joanne E. II. Title. R729.8.M665 2004 362.1—dc22 2004002758 Printed in the United States of America FIRSTEDITION HB Printing 10 9 8 7 6 5 4 3 2 1 ftoc.qxd 11/11/04 9:54 AM Page vii CONTENTS Foreword ix Lucian L. Leape Preface xv Acknowledgments xxiii The Authors xxvii Introduction 1 1 Declare Patient Safety Urgent and a Priority 12 2 Error and Harm in Health Care 23 3 Understanding the Basics of Patient Safety 44 4 Assume Executive Responsibility 71 5 Import New Knowledge and Skills 96 6 Install a Blameless Reporting System 120 7 Assign Accountability 148 8 Align External Controls and Reform Education 181 vii ftoc.qxd 11/11/04 9:54 AM Page viii viii Contents 9 Accelerate Change For Improvement 204 10 The End of the Beginning 234 References 245 Glossary 255 Appendixes 1 Checklist for Assessing Institutional Resilience 279 2 Creating De-Identified Case Studies for Dissemination 283 3 Medical Accidents Policy: Reporting and Disclosure, Including Sentinel Events 285 4 Medication Safety Team Feedback Form 295 5 Patient Safety Workplan 297 6 Safety Learning Report 300 7 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 303 8 Complexity Lens Reflection 308 9 A Brief Look at Gaps in the Continuity of Care 311 10 A Brief Look at the New Look in Complex System Failure, Error, and Safety 313 11 A Reminder on Every Chart 315 12 List of Serious Reportable Events inHealth Care 316 13 Statement of Principle: Talking to Patients About Health Care Injury 321 14 VHA Patient Safety Organizational Assessment 322 Additional Readings 331 Resources 335 Index 345
The list of books you might like
