To Do No Harm: Ensuring Patient Safety in Health Care OrganizationsISBN: 978-1-118-01610-7
Paperback
386 pages
October 2010, Jossey-Bass
Other Available Formats: E-book
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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
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 in Health 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