Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition

Figures, Tables, and Exhibits v

Foreword ix
Lucian L. Leape

Preface xi

The Editor xvii

The Authors xix

PART ONE: The Basics of Patient Safety

Chapter 1 A Formula for Errors: Good People + Bad Systems 3
Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin

Chapter 2 The Human Side of Medical Mistakes 21
Sven Ternov

Chapter 3 High Reliability and Patient Safety 35
Yosef D. Dlugacz and Patrice L. Spath

PART TWO: Measure and Evaluate Patient Safety

Chapter 4 Measuring Patient Safety Performance 59
Karen Ferraco and Patrice L. Spath

Chapter 5 Analyzing Patient Safety Performance 103
Karen Ferraco and Patrice L. Spath

Chapter 6 Using Performance Data to Prioritize Safety Improvement Projects 119
Robert Latino

PART THREE: Reactive and Proactive Safety Investigations

Chapter 7 Accident Investigation and Anticipatory Failure Analysis 143
Sanford E. Feldman and Douglas W. Roblin

Chapter 8 MTO and DEB Analysis Can Find System Breakdowns 157
Sven Ternov

Chapter 9 Using Deductive Analysis to Examine Adverse Events 171
Robert Latino

PART FOUR: How to Make Health Care Processes Safer

Chapter 10 Proactively Error-Proofing Health Care Processes 197
Richard J. Croteau and Paul M. Schyve

Chapter 11 Reducing Errors Through Work System Improvements 217
Patrice L. Spath

Chapter 12 Improve Patient Safety with Lean Techniques 245
Danielle Lavallee

PART FIVE: Focused Patient Safety Initiatives

Chapter 13 How Information Technology Can Improve Patient Safety 269
Donna J. Slovensky and Nir Menachemi

Chapter 14 A Structured Teamwork System to Reduce Clinical Errors 297
Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey

Chapter 15 Medication Safety Improvement 335
Yosef D. Dlugacz

Glossary 369

Index 383