Edited by Albert W. Wu, MD, MPH, Johns Hopkins University, a world-renown expert in patient safety
Foreword by James Reason, PhD
Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event.
Health care, by its very nature, makes slips, lapses, and mistakes highly likely. Yet health care professionals—and physicians in particular—are taught very little about the varieties of human fallibility and the conditions likely to provoke them. They are raised in a culture of trained perfectibility. The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm consists of two parts. Part 1 (Chapters 1–5) provides a guide to what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. Part II (Chapters 6–20) provides 15 detailed case studies from a variety of clinical disciplines and specialties to show how the health care organizations in which the close calls occurred used them to identify, investigate, and solve patient safety problems.
Praise for The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm
“Wu and colleagues present the art and science of analyzing close calls--cases in which we could have harmed or killed a patient but didn't through some combination of good luck and good catches–in a clear and accessible manner. This superb book tells us why analyzing close calls is so important to patient safety and shows us how to do it. It should be on the bookshelf of everyone interested in keeping patients safe.”
—Robert M. Wachter, M.D., University of California, San Francisco
“This succinct and focused book, which demonstrates how close calls have been used to solve safety problems, is a must read for anyone with responsibility for patient safety.”
—Evan M. Benjamin, M.D., F.A.C.P., Senior Vice President for Healthcare Quality, Baystate Health, Springfield, Massachusetts.
“Learning from close calls is critical to safety but hard to do in practice. This book brings the concepts and ideas to life in rich examples that reveal the errors, the system failures, the heroic recoveries, and the many roads to system safety. It is invaluable for all clinical teams as they seek to put principles into practice to ensure the safety of their patients.”
—Charles Vincent, Ph.D., Professor of Clinical Safety Research, Imperial College of Science, Technology and Medicine, London
Concept of close calls and how to identify them
Reporting close calls
Using close calls to identify and solve larger patient safety problems
Human factors applications
Forward by human error expert James Reason, Ph.D.
Authoritative tutorials based on the literature
Detailed case studies from a variety of clinical disciplines and specialties
Standards: Related to Leadership (LD)
Setting: All accreditation settings
Key Audience: Medical directors, patient safety officers, risk managers, performance improvement professionals, physicians, physician assistants, nurses, nurse practitioners, pharmacists