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The Value of Close Calls in Improving Patient Safety

Prevent today's close call from turning into tomorrow's catastrophic event!

January 2011. 200 pages.

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Product Description

Product Description

Edited by Albert W. Wu, MD, MPH, Johns Hopkins University, a world-renowned 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
 
Key Topics: 
  • 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
Key Features: 
  • 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
 
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Table of Contents

Table of Contents

Contributors

Foreword

James Reason, Ph.D.

Introduction

AlbertW.Wu, M.D., M.P.H.

Part I. Close Calls and Patient Safety

 
Chapter 1 Close Calls in Health Care
Fiona Pathiraja, M.B.B.S., B.Sc., D.H.M.S.A., D.R.C.O.G.; Marie-Claire Wilson, M.A.(Cantab), M.B.B.S.; Peter J. Pronovost, M.D., Ph.D.
 
Chapter 2 Reporting and Learning from Close Calls
Alan Fayaz, M.A.(Cantab), M.B.B.S., M.R.C.P.; Laura Morlock, Ph.D.
 
Chapter 3 Promoting Meaningful Close-Call Reporting: Lessons from Aviation
Sidney W.A. Dekker, Ph.D.
 
Chapter 4 Human Factors Applications to Understanding and Using Close Calls to Improve Health Care
Tosha B. Wetterneck, M.D., M.S.; Ben-Tzion Karsh, Ph.D.
 
Chapter 5 Disclosing Close Calls to Patients and Their Families
Albert W. Wu, M.D., M.P.H.; Thomas H. Gallagher, M.D.; Rick Iedema, Ph.D.
 

Part II. Case Studies of Close Calls

Event Prevented Before Reaching the Patient
 
Chapter 6 Outpatient Endoscopy: Closing the Loop on Colonoscopy Orders
Lydia C. Siegel, M.D., M.P.H.; Tejal K. Gandhi, M.D., M.P.H.
 
Chapter 7 Medication Safety: Neuromuscular Blocking Agents
David U, M.Sc.(Pharm.); Bonnie Salsman, B.Sc.(Pharm.)
 
Chapter 8 Oncology: The Patient’s Family Speaks Up
Saul N. Weingart, M.D., Ph.D.; Audrea Szabatura, Pharm.D., B.C.O.P.; Deborah Duncombe, M.H.P.; Sarah Kadish, M.S.; Amy Billett, M.D.; Sylvia Bartel, R.Ph., M.P.H.
 
Chapter 9 Surgery: Safety Culture, Site Marking, Checklists, and Teamwork
Andrew M. Ibrahim; Martin A. Makary, M.D., M.P.H.
Barbara Rabin Fastman, M.H.A., M.T.(A.S.C.P.)S.C., B.B.; Harold S. Kaplan, M.D.
Event Reached the Patient but Did No Harm
 
Chapter 10 Transfusion Medicine: The Problem with Multitasking
Barbara Rabin Fastman, M.H.A., M.T.(A.S.C.P.)S.C., B.B.; Harold S. Kaplan, M.D.
 
Chapter 11 Radiotherapy: Using Risk Profiling to Identify Errors and Close Calls
in the Process of Care
Michael B. Barton, M.B.B.S., M.D.; Geoffrey P. Delaney, M.B.B.S., M.D., Ph.D.;
Douglas J. Noble, B.Sc., B.M., B.Ch., M.P.H.
 
Chapter 12 Health Information Technology: Look-Alikes in the Drop-Down Menu
Erika Abramson, M.D., M.Sc.; Rainu Kaushal, M.D., M.P.H.
 
Chapter 13 Pediatrics: “Wrong Patient” Breast-Milk Administration in the Neonatal Intensive Care Unit
Michael L. Rinke, M.D.; Julie Murphy, R.N., B.S.N., I.B.C.L.C.; David G. Bundy, M.D., M.P.H.
 
Chapter 14 Psychiatry: Mistaken Identity in a Patient with Schizophrenia
Geetha Jayaram, M.D., M.B.A.; Jennifer Meuchel, M.D.
Event Reached the Patient, but Harm Was Mitigated
 
Chapter 15 Anesthesia: Administration of Sedatives to Patients Receiving Epidural Analgesia
Stephen Pratt, M.D.
 
Chapter 16 Emergency Medicine: Medication Displacement in an Automated Medication
Dispensing System
Sommer Gripper, M.D.; Elizabeth Fang, Pharm.D., B.C.P.S.; Sneha Shah, M.D.; Melinda Ortmann, Pharm.D., B.C.P.S.; Michelle Patch, R.N., M.S.N.; Jordan Sax, M.D.; Julius Cuong Pham, M.D., Ph.D.
 
Chapter 17 Obstetrics: Pulmonary Edema Following a Failed Handoff
Susan Mann, M.D.; Stephen D. Pratt, M.D.
 
Chapter 18 Radiology: A Chance Discovery of Retained Sponges
Anthony Fotenos, M.D., Ph.D.; John Eng, M.D.
 
Chapter 19 Geriatrics: Improving Medication Safety in the Nursing Home Setting—
The Case of Warfarin
Jerry H. Gurwitz, M.D.; Terry Field, D.Sc.; Jennifer Tjia, M.D., M.S.C.E.; Kathleen Mazor, Ed.D.
 
Chapter 20 Laboratory Medicine/Pathology: Improving Diagnostic Safety in Papanicolaou Smears
Lee Hilborne, M.D., M.P.H.; Maria Olvera, M.D.; Dereck C. Counter, M.B.A.; Toni L. Kick, Ph.D.; Stephen C. Suffin, M.D.

Index

 

Contributors

Contributors

About the Editor


Albert W. Wu, MD, MPH, is a professor at Johns Hopkins Bloomberg School of Public Health where he teaches Health Policy and Management; has joint appointments in Epidemiology, International Health, Medicine, and Surgery; and is the director at the Center for Health Services and Research Outcomes. Previously he was a senior advisor for the World Health Organization. He received his doctor of medicine degree from Weill Medical College of Cornell University and his masters of public health from the University of California, Berkeley.

About the Foreword Writer

 
James Reason, PhD, considered one of the founding fathers of the patient safety field, was a professor of Psychology at the University of Manchester. He earned his bachelor of science degree from the University of Manchester and he earned his doctor of philosophy in psychology from the University of Leicester. Reason has done a wide range of research regarding human error in health care and has written multiple books on his findings, including the landmarks Human Error and Managing the Risks of Organizational Accidents. His error classification and models of system breakdown (the “Swiss Cheese” model) are widely used.

About the Authors


The following authors contributed to The Value of Close Calls in Improving Patient Safety:
  • Fiona Pathiraja, MBBS, DHMSA, DRCOG, clinical advisor to Professor Sir Bruce Keogh, National Health Service (NHS) medical director, Department of Health (England), London
  • Marie-Claire Wilson, MA (Cantab), MBBS, independent consultant, London
  • Peter J. Pronovost, MD, PhD, professor, Quality and Safety Research Group, Department of Anesthesiology and Critical Care Medicine, and Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health; and a member of The Joint Commission Journal on Quality and Patient Safety Editorial Advisory Board
  • Alan Fayaz, MA (Cantab), MBBS, MRCP, formerly clinical advisor to medical director, National Patient Safety Agency, London; specialist trainee in Anaesthesia and Intensive Care, North East London Rotation
  • Laura Morlock, PhD, professor and associate chair for Health Management Programs, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
  • Sidney WA Dekker, PhD, professor and director, Key Centre for Ethics, Law, Justice and Governance, Griffith University
  • Tosha B. Wetterneck, MD, MS, associate professor of medicine, Division of General Internal Medicine, University of Wisconsin (UW) School of Medicine and Public Health; and researcher, Center for Quality and Productivity Improvement, UW–Madison
  • Ben-Tzion Karsh, PhD, associate professor of Industrial and Systems Engineering, UW–Madison
  • Thomas H. Gallagher, MD, associate professor of medicine, Department of General Internal Medicine, University of Washington School of Medicine
  • Rick Iedema, PhD, professor of organizational communication and director, Centre for Health Communication, University of Technology, Sydney, Australia
  • Lydia C. Siegel, MD, MPH, associate physician, Brigham and Women’s Hospital, Boston; and instructor, Harvard Medical School
  • Tejal K. Gandhi, MD, MPH, director of patient safety, Partners Healthcare, Boston; associate physician at Brigham and Women’s Hospital, Boston; and associate professor of medicine, Harvard Medical School
  • David U, MSc (Pharm), president and chief executive officer, Institute for Safe Medication Practices Canada (ISMP Canada)
  • Bonnie Salsman, BSc (Pharm), consultant pharmacist, ISMP Canada
  • Saul N. Weingart, MD, PhD, vice president for quality improvement and patient safety, Dana-Farber Cancer Institute, Boston; and associate professor of Medicine, Harvard Medical School
  • Audrea Szabatura, PharmD, BCOP, medication safety officer, Dana-Farber Cancer Institute, Boston
  • Deborah Duncombe, MPH, risk manager, Dana-Farber Cancer Institute, Boston
  • Sarah Kadish, MS, director of process improvement, Dana-Farber Cancer Institute
  • Amy Billett, MD, director of safety and quality, Division of Pediatric Hematology/ Oncology, Dana-Farber Cancer Institute and Children’s Hospital, and associate professor of pediatrics, Harvard Medical School
  • Sylvia Bartel, RPh, MPH, vice president of pharmacy, Dana-Farber Cancer Institute
  • Andrew M. Ibrahim, Doris Duke Clinical Research Fellow, Department of Surgery, Johns Hopkins University School of Medicine
  • Martin A. Makary, MD, MPH, associate professor of surgery and health policy and management, Johns Hopkins University School of Medicine; and codirector, The Quality and Safety Research Group, Johns Hopkins Hospital
  • Barbara Rabin Fastman, MHA, MT (ASCP) SC, BB assistant professor, Mount Sinai School of Medicine, New York City
  • Harold S. Kaplan, MD, professor, Health Evidence and Policy, Mount Sinai School of Medicine, New York City
  • Michael B. Barton, MBBS, MD, professor of radiation oncology, South West Clinical School, University of New South Wales (NSW); and senior staff specialist, Liverpool Cancer Therapy Centre, Liverpool, NSW, Australia
  • Geoffrey P. Delaney, MBBS, MD, PhD, clinical professor, South West Clinical School, University of NSW; and area director of cancer services, Sydney South West Area Health Service, NSW, Australia
  • Douglas J. Noble, BM, BCh, MPH, public health registrar, London Deanery, London; and research fellow, Green Templeton College, University of Oxford, Oxford, United Kingdom
  • Erika Abramson, MD, MSc, assistant professor of pediatrics; and associate program director, pediatric graduate medical education, Division of Quality and Medical Informatics, Weill Medical College of Cornell University, New York City; and assistant attending pediatrician, New York-Presbyterian Hospital, New York City
  • Rainu Kaushal, MD, MPH, associate professor of pediatrics, medicine and public health, Weill Cornell Medical College; chief of the division of quality and medical informatics, Department of Pediatrics; director of pediatric quality and safety, Komansky Center for Children’s Health, NYPH; and executive director, Health Information Technology Evaluation Collaborative, New York City
  • Michael L. Rinke, MD, instructor of pediatrics, division of quality and safety, Johns Hopkins University School of Medicine, Baltimore
  • Julie Murphy, RN, BSN, IBCLC, registered nurse and certified lactation consultant, Neonatal Intensive Care Unit, Johns Hopkins Hospital, Baltimore
  • David G. Bundy, MD, MPH, assistant professor of pediatrics, Johns Hopkins University School of Medicine, Baltimore
  • Geetha Jayaram, MD, MBA, associate professor, Department of Psychiatry, Johns Hopkins Hospital, Baltimore; and associate professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore
  • Jennifer Meuchel, MD, clinical associate, Community Psychiatry Program, Johns Hopkins Hospital
  • Stephen Pratt, MD, chief, Division of Quality and Safety, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston
  • Sommer Gripper, MD, emergency medicine physician, Johns Hopkins Hospital, Baltimore
  • Elizabeth Fang, PharmD, BCPS, pharmacy resident, Department of Pharmacy, Johns Hopkins Hospital, Baltimore
  • Sneha Shah, MD, emergency medicine resident, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore
  • Melinda Ortmann, PharmD, BCPS, clinical pharmacist, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore
  • Michelle Patch, RN, MSN, safety officer, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore
  • Jordan Sax, MD, emergency medicine resident, Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore
  • Julius Cuong Pham, MD, PhD, assistant professor, Departments of Emergency Medicine, Anesthesia and Critical Care, and Surgery, Johns Hopkins School of Medicine, Baltimore
  • Susan Mann, MD, director of team training and simulation, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston
  • Stephen Pratt, MD, formerly clinical director, obstetric anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, is chief, Division of Quality and Safety, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center
  • Anthony Fotenos, MD, PhD, radiology resident, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore
  • John Eng, MD, associate professor of radiology and health sciences informatics, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore
  • Jerry H. Gurwitz, MD, executive director, Meyers Primary Care Institute, Worcester, Massachusetts; and professor of medicine and of family medicine and community health, University of Massachusetts Medical School, Worcester
  • Terry Field, DSc, associate director, Meyers Primary Care Institute; and associate professor of medicine, University of Massachusetts Medical School
  • Jennifer Tjia, MD, MSCE, assistant professor of medicine, University of Massachusetts Medical School
  • Kathleen Mazor, EdD, associate professor of medicine, University of Massachusetts Medical School
  • Lee Hilborne, MD, MPH, professor of pathology and laboratory medicine, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles; medical director, Quest Diagnostics, West Hills, California; and deputy director, Global Health, RAND, Santa Monica, California
  • Maria Olvera, MD, senior pathologist, Quest Diagnostics, West Hills, California
  • Dereck C. Counter, MBA, six sigma black belt, Quest Diagnostics, Madison, New Jersey
  • Toni L. Kick, PhD, six sigma master black belt, Quest Diagnostics, Madison, New Jersey
  • Stephen C. Suffin, MD, chief laboratory officer, Quest Diagnostics, Madison, New Jersey

 

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