Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 4
Education and Training
- Students 1
Error Reporting and Analysis
- Error Reporting 13
- Human Factors Engineering 3
- Legal and Policy Approaches 6
- Policies and Operations 2
- Quality Improvement Strategies 5
- Research Directions 1
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 5
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 2
- Medication Safety 3
- Psychological and Social Complications
- Surgical Complications 3
- Family Members and Caregivers 2
- Health Care Executives and Administrators 31
- Health Care Providers 26
- Non-Health Care Professionals 23
- Patients 9
Search results for "Psychological and Social Complications"
- Psychological and Social Complications
Weick KE. Thousand Oaks, CA: Sage Publications; 1995.
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen in his story Escape Fire, which illustrates the disasters that befall teams when "sensemaking" is absent or disappears in a crisis. Weick's thinking encompasses the notion that both individuals and teams often overlook important problems because they put on cognitive blinders based on their biases and expectations and that individuals or teams working in complex enterprises often err because they lose the ability to make rational decisions in the face of crises. All of this is useful and intuitively logical, although one finishes Weick's book not entirely sure how to improve sensemaking in a clinical context.
Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. San Francisco, CA: Jossey-Bass; 1993. ISBN 9781555425449.
Authored by several leaders of the Picker/Commonwealth Program for Patient-Centered Care, this book demonstrates the broad impact of the program. The authors discuss the key tenets of patient-centered care, drawing on empirical research, theory, and results of many surveys of patients, providers, and administrators. The authors provide many practical suggestions, a number of which have been adopted since the book's first publication in 1993. Examples include giving patients access to their medical records, giving them ''written and/or visual information identifying members of the clinical team," and offering ''culturally sensitive educational materials tailored to specific ethnic groups.''
Paget MA. Philadelphia, PA: Temple University Press; 1988. ISBN: 0877225338.
In this often described landmark text on the nature of medical error, Marianne Paget uses a detailed series of physician interviews to illustrate the complexities of mistakes in medicine. She carefully describes the language associated with concepts such as mistake, fault, negligence, and blame. She provides a thoughtful and provocative analysis of these clinical events and probes how physicians think about their mistakes, including the associated psychological burden in confronting them. The large number of actual transcripts shared throughout her text creates opportunities to get inside the head of well-intentioned physicians who struggle with avoiding mistakes.
Patient Safety Ethics: How Vigilance, Mindfulness, Compliance, and Humility can Make Healthcare Safer.
Banja JD. Baltimore, MD: Johns Hopkins University Press; 2019. ISBN: 9781421429083.
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.
Gosport Independent Panel. London, England: Crown Copyright; 2018. ISBN: 9781528604062.
Organizational culture influences how comfortable individuals are with raising awareness of conditions that diminish patient safety. This independent inquiry report provides case studies and a detailed analysis of conditions that hindered nurses and families from acquiring answers about care concerns. The analysis determined factors such as hierarchy and poor physician regard for nursing expertise as persistent challenges to safety in health care.
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ Publication No. 16-0017-EF.
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Denver, CO: Healthgrades Operating Company, Inc; 2015.
Analyzing data from the Hospital Consumer Assessment of Healthcare Providers and Systems, this report discusses hospital efforts to understand measures of patient experience and reveals how 32 institutions recognized for their patient safety status were found to have had improved outcomes over time as demonstrated through the application of patient safety indicators. The publication includes a list of hospitals that received the 2015 Healthgrades Patient Safety Excellence Award.
Chicago, IL: Health Research & Educational Trust; 2015.
Patient and family advisor programs have been implemented in health care as a way to incorporate the experiences of consumers into safety improvement work. This guide provides a framework to help hospitals develop partnership initiatives that focus on advisor recruitment, education, and teamwork to enhance efforts to engage patients and families in this role.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
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.
Poll: Many Sick Americans Experience Significant Financial Problems and Report Their Care is not Well-Managed.
Princeton, NJ: Robert Wood Johnson Foundation, National Public Radio, and the Harvard School of Public Health. May 21, 2012.
This report describes findings from a poll that investigated how cost of care and health insurance affect patients' experiences of health care quality and safety in the United States.
Gupta S. New York, NY: Grand Central Publishing; 2012. ISBN: 9780446583855.
To illustrate how physicians learn from mistakes, this novel (written by CNN medical correspondent Dr. Sanjay Gupta) explores the impact of a medical error on surgeons at one hospital.
London, UK: Health Policy & Economic Research Unit, British Medical Association Scotland; May 2010.
This report summarizes findings from a survey querying physicians about United Kingdom National Health Service whistleblowing policies.
Chabris C, Simons D. New York, NY: Crown Publishing Group; 2010. ISBN: 0307459659.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
Oakbrook Terrace, IL: Joint Commission Resources; 2008. ISBN: 9781599402291.
This handbook describes characteristics of the health care work environment that contribute to fatigue and burnout and introduces strategies to address them.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.
This report summarizes 2007 data on quality and safety issues in Medicare- and Medicaid-certified nursing homes and finds that 17% of the organizations were cited for care deficiencies that could result in harm to residents.