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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.

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



James Reason, Ph.D.


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.