Narrow Results Clear All
- Communication Improvement 23
- Culture of Safety 20
- Education and Training 17
- Error Reporting and Analysis 12
- Human Factors Engineering 9
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 17
- Specialization of Care 4
- Technologic Approaches 3
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 5
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications 5
- Internal Medicine 12
- Surgery 4
- Nursing 2
- Health Care Executives and Administrators 39
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
- Patients 1
Search results for "Book/Report"
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Boston, MA: Institute for Healthcare Improvement; 2019.
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
Complex systems are prone to failure. This book provides a multi-industry discussion of factors that contribute to failure. The authors highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure, and poorly designed safety strategies can unintentionally contribute to harm. Recommended strategies to manage risks include those utilized in patient safety work, such as multidisciplinary teamwork, process design, and systems thinking.
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance—A Handbook for Acute Care Health Professionals.
Brindley P, Cardinal P, eds. Ottawa, ON, Canada: Royal College of Physicians and Surgeons of Canada; 2017. ISBN: 9781926588414.
Nontechnical skill development has gained attention as a way to enhance patient safety. This publication highlights how crisis resource management can help develop nontechnical expertise to enhance team performance. Strategies covered in the text include situational awareness, team communication, decision making, and leadership in the acute care environment.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Chicago, IL: Health Research & Educational Trust; June 2015.
This guide draws from the experience of organizations that have used TeamSTEPPS to illustrate how the program has contributed to patient safety and quality improvement efforts. Lessons learned include the value of engaging leadership, utilizing debriefing as a learning mechanism, and the need to avoid a one-size-fits-all approach to training.
Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.
Sommers LS, Launer J, eds. New York, NY: Springer; 2013. ISBN: 9781461468110.
This book introduces the role of clinical uncertainty in primary care practice and describes four approaches to promote collaborative decision making. The authors use case vignettes to illustrate how uncertainty can be resolved through group discussions to inform and confirm clinical judgment.
This Web site summarizes patient safety improvement efforts in Tennessee and provides access to an annual report of their efforts and a calendar of training opportunities.
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
Health care has been recently been directed toward focusing on the value of teamwork in reducing risks. This publication provides extensive information about team training, including key concepts, guidelines, insights from health care workers, and strategies to improve teamwork and monitor performance.
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide For Hospitals.
Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 12-0041.
Edmondson AC, Schein EH. San Franscisco, CA: Jossey-Bass; 2012. ISBN: 9780787970932.
This book explores teamwork, including barriers to effective teamwork and tactics to enhance professional and organizational learning.
Dekker S. New York, NY: CRC Press; 2011. ISBN: 1439852251.
This book explores the complexity of patient safety improvement through the lens of human factors engineering and provides practical avenues for its application.
Spath PL, ed. San Francisco, CA: Jossey-Bass; 2011. ISBN: 9780470502402.
Error Reduction in Health Care remains one of the few comprehensive textbooks in patient safety. This updated edition covers key concepts in safety, beginning with the systems approach and the role of human factors engineering in patient safety. Also included are sections on measurement and interpretation of safety data, error analysis techniques, and approaches to improving patient safety (e.g., teamwork training and developing a culture of safety). The book's chapters are authored by experts in the field and strike a balance between background theory and practical approaches to reducing preventable adverse events.
Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.
This publication provides various strategies to drive innovation in patient safety, including how to eliminate unsafe practices.
Sculli GL, Sine DM. Danvers, MA: HCPro, Inc; 2011. ISBN: 9781601467836.
This book describes how to apply aviation communication tactics to nursing practice.