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- Communication Improvement 14
- Culture of Safety 18
Education and Training
- Students 1
- Error Reporting and Analysis 15
- Human Factors Engineering 9
- Legal and Policy Approaches 4
- Logistical Approaches 2
- Policies and Operations 1
- Quality Improvement Strategies 15
- Teamwork 9
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Medical Complications 3
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 10
- Second victims 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators 54
Health Care Providers
- Nurses 1
- Non-Health Care Professionals
- Patients 3
Search results for "Book/Report"
- Organizational Behaviorists
Topol E. New York, NY: Basic Books; 2019. ISBN: 978-1541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.
Kreitzer MJ, Carter K, Coffey DS, et al. NAM Perspectives. Washington, DC: National Academy of Medicine; 2019.
Burnout can diminish the safety of clinicians, students, health care workers, and patients. This report suggests institutions apply design thinking and systems thinking methods to develop interventions to reduce burnout and stress. A past Annual Perspective covered the impact of burnout on patient safety.
Howard J. Cham, Switzerland: Springer Nature Switzerland; 2019. ISBN: 9783319932231.
Cognitive biases contribute to diagnostic missteps, delays, and errors. This publication uses case-based illustrations to explore the effect of common cognitive biases (e.g., confirmation, anchoring, and overconfidence) on care. The author suggests feedback, healthy skepticism, and open discussion as tactics to reduce errors stemming from bias in decision-making.
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
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.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Graban M. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781498743259.
Lean methodology focuses on establishing a culture that supports employee safety and drives process improvement. This book provides information about Lean and how to implement such concepts to integrate quality and safety behaviors in health care delivery. One chapter focuses on the use of root cause problem-solving and error prevention. The author spoke about applying Lean in hospitals in a previous PSNet interview .
First Report of Session 2016–17 Report. House of Commons Public Administration and Constitutional Affairs Committee. London, England: The Stationery Office; May 24, 2016. Publication HC 94.
Complaint investigations must be conducted in a consistent manner with a goal of learning from each incident to prevent similar occurrences. This government report summarizes an inquiry into the United Kingdom National Health Service complaint reporting system and suggests that support and training for staff must improve in order to address complaints effectively.
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Schneider EC, Ridgely MS, Quigley DD, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-0027-EF.
Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.
Oster C, Braaten J, eds. Indianapolis, IN: Sigma Theta Tau International; 2016. ISBN: 9781940446387.
Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296.
Manchester, UK: General Medical Council; November 2014.
Zipperer L, ed. London, UK: Gower Publishing; 2014. ISBN: 9781409438571.
Building a Culture of Candour: a Review of the Threshold for the Duty of Candour and of the Incentives for Care Organisations to Be Candid.
Dalton D, Williams N. London, UK: The Royal College of Surgeons of England; March 2014.
When medical errors occur, patients desire full disclosure. This report calls for clinicians in the National Health Service to disclose errors that contribute to moderate or severe harm or death. The authors outline recommendations to help organizations establish a safety culture that requires discussion about unanticipated events and ensures that staff receive training in apologies.
Thorlby R, Smith J, Williams S, Dayan M. London, UK: Nuffield Trust; February 2014.
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013. Publication GAO-14-55.
Evaluation of provider behavior can identify problems that affect patient safety. This report analyzed data and expert interviews from four Veterans Affairs medical centers to identify weaknesses in peer review processes. Investigators found inconsistent adherence to peer review policy elements, such as timely review performance and peer review trigger development, and make recommendations to drive actions that address these issues.
O'Hara J, Isden R. London, UK: Health Foundation; October 2013.
Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.
Geneva, Switzerland: World Health Organization; 2013. ISBN: 9789241505475.
This guide poses ethical questions for patient safety researchers to help them evaluate and prevent risks inherent in research design.
Sevdalis N. London, UK: The Health Foundation; June 2013.