Contentes

Preface, xi

Section I: An Introduction to Patient Safety and Medical Errors

Chapter 1

The Nature and Frequency Of Medical Errors and Adverse Events, 3

Chapter 2

Basic Principles of Patient Safety, 21

Chapter 3

Safety, Quality, and Value, 35

Section II: Types of Medical Errors

Chapter 4

Medication Errors, 57

Chapter 5

Surgical Errors, 77

Chapter 6

Diagnostic Errors, 101

Chapter 7

Human Factors and Errors at the Person–Machine Interface, 121

Chapter 8

Transition and Handoff Errors, 135

Chapter 9

Teamwork and Communication Errors, 159

Chapter 10

Healthcare-Associated Infections, 171

Chapter 11

Other Complications of Healthcare, 191

Chapter 12

Patient Safety in the Ambulatory Setting, 205

Section III: Solutions

Chapter 13

Information Technology, 219

Chapter 14

Reporting Systems, Root Cause Analysis, and Other Methods of Understanding Safety Issues, 257

Chapter 15

Creating a culture of safety, 281

Chapter 16

Workforce Issues, 307

Chapter 17

Education and Training Issues, 331

Chapter 18

The Malpractice System, 349

Chapter 19

Accountability, 371

Chapter 20

Accreditation and Regulations, 389

Chapter 21

The Role of Patients, 403

Chapter 22

Organizing a Safety Program, 415

Conclusion, 441

Section IV: Appendices

APPENDIX I

 Key Books, Reports, Series, and Websites on Patient Safety, 445

APPENDIX II

The Ahrq Patient Safety Network (AHRQ PSNET) Glossary of Selected Terms in Patient Safety, 453

APPENDIX III

Selected Milestones in the Field of Patient Safety, 485

APPENDIX IV

The Joint Commission’s National Patient Safety Goals (Hospital Version, 2017), 487

APPENDIX V

 Agency For Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs), 488

APPENDIX VI

The National Quality Forum’s List of Serious Reportable Events 2011, 489

 APPENDIX VII

 The National Quality Forum’s List of “Safe Practices for Better Healthcare—2010 Update”, 491

 APPENDIX VIII

 Medicare’s “No Pay for Errors” List*, 494

APPENDIX IX

Things Patients and Families Can Do, and Questions They Can Ask, To Improve Their Chances Of Remaining Safe In The Hospital, 495

Index , 499