The Patient Safety Handbook

Learn from other high-reliability industries—See how building a safe environment required leaders in the commercial airline, nuclear power, and automobile industries to challenge assumptions about their mission, core competencies, market, technology, and structures of their organizations' operations. 

Create a healing organizational culture—Strategies are presented for refocusing your organization's environment from a culture of blame to a culture of sustainable change and trust that welcomes error detection and reporting as an opportunity to improve patient care and patient safety.

Understand why things go wrong—Learn what is gained through the investigation and analysis of clinical incidents, and benefit from the advice of noted experts as they present strategies for moving forward.

Joint Commission Standards defined—An overview of the JCAHO standards for patient safety and medical/health care error reduction helps you to interpret what the standards mean for your organization and how to ensure that you are compliant.

Utilize the concepts of epidemiology—Apply epidemiologic tools to augment your understanding of medical errors, and complement traditional case examination approaches. 

Lead your organization through teamwork—Nowhere will you find a more in-depth discussion of teams, teamwork, collaboration, and communication—essential skills necessary to coordinate and implement a highly-integrated, organization-wide safety program.

Benefit from authoritative, hands-on guidance—Fulfill your commitment to improved patient safety, risk reduction, and renewed health care consumer confidence using the practical strategies outlined in this comprehensive reference. 

Introduction by Mildred K. Lehman
Chapter 1: Understanding the First IOM Report and Its Impact on Patient Safety
Chapter 2: The Second Report on Safety from the IOM: Crossing the Quality Chasm
Chapter 3: Interpersonal Relationships: The "Soft Stuff" of Patient Safety
Chapter 4: An Organization Development Framework for Transformation to a Culture of Safety
Chapter 5: Toward a Philosophy of Patient Safety: Expanding the Systems Approach to Medical Error
Chapter 6: The Fallacy of the Body Count: Why the Interest in Patient Safety and Why Now?
Chapter 7: Fallacies on Counting Error
Chapter 8: The Investigation and Analysis on Clinical Incidents
Chapter 9: Patient Safety and Errors Reduction Standards
Chapter 10: Applying Epidemiology in Patient Safety
Chapter 11: Patient Safety Is an Organizational Systems Issue: Lessons from a Variety of Industries
Chapter 12: Admitting Imperfection: Revelations from the Cockpit for the World of Medicine
Chapter 13: Reporting and Preventing Medical Mishaps: Safety Lessons Learned from Nuclear Power
Chapter 14: Trial and Error in My Quest to be a Partner in My Healthcare
Chapter 15: Health Care Literacy and Patient Safety: The New Paradox
Chapter 16: Using Root Cause Analysis to Analyze Issues of Safety
Chapter 17: The Leadership Role of the Chief Operating Officer in Aligning Strategy and Operations
Chapter 18: The Successful Quality Professional: Framework, Attributes, and Roles
Chapter 19: The Role of the Risk Manager in Creating Patient Safety
Chapter 20: Reducing Medical Errors: The Role of the Physician
Chapter 21: Engaging General Counsel in the Pursuit of safety
Chapter 22: Growing Nursing Leadership in the Field of Patient Safety
Chapter 23: Engaging the Board of Directors and Creating a Governance Structure
chapter 24: Teamwork Communications and Training
Chapter 25: Teamwork: The Fundamental Building Block of High Reliability Organizations and Patient Safety
Chapter 26: Moving Beyond Blame to Create an Environment that Rewards Reporting
Chapter 27: Addressing Clinician Performance Problems as a Systems Issue
Chapter 28: Advancing Patient Complaint and Healthcare Worker Safety by Preventing Infections
Chapter 29: The Baldridge Approach to Patient Safety
Chapter 30: Outlining the Business Case for Patient Safety
Chapter 31: The Economics of Patient Safety
Chapter 32: The Role of Ethics and Ethics Services in Patient Safety
Chapter 33: What Can One Learn from the Canadian Approach to Patient Safety?
Chapter 34: How We Started Patient Safety in Israel
Chapter 35: Public Legislation and Professional Self-Regulation: Quality and Safety Efforts in Norwegian Health Care
Chapter 36: The Handling of a Catastrophic Medical Error Event: A Case Study
Chapter 37: Why, What, and How Ought Harmed Parties be Told? The Art, Mechanics, and Ambiguities
Chapter 38: Disclosure of Medical Error: Liability, Insurance, and Risk Management Implications
Chapter 39: Medical Error and Patient Safety: Communicating with the Media
Chapter 40: Using Best Practices to Improve Medication Safety
Chapter 41: Improving the Safety of the Medication Use Process
Chapter 42: Designing a Safer Systems for Medications: A Case Study
Chapter 43: One Organization's Advocacy Effort for Error Prevention: Institute For Safe Medical Practices
Chapter 44: The Role of the Laboratory in Patient Safety
Chapter 45: Partnership and Collaboration on Patient Safety with Health Care Suppliers
Chapter 46: Patient Safety Training and New Technology
Chapter 47: No-Fault Compensation for Medical Injuries: Prospect for Error Prevention
Chapter 48: The Criminalization of Health Care: When is Medical Malpractice a Crime?
Chapter 49: That Does the Leapfrog Group Portend for Health Care Providers?
Chapter 50: The Future of Patient Safety: Reflections on History, the Data, and What it Will take to Succeed

• "[The Patient Safety Handbook] cuts a wide swath through the discipline of patient safety, including principles, policies, ethics, and legal ramifications. It provides a "one-stop" resource for persons needing a reference covering the spectrum of patient safety. The chapter authors constitute a "who's who" of patient safety in terms of name recognition. The book is primarily text, with a few illustrations and tables in some of the chapters.

  This is the best reference in patient safety available at this time. It should be of interest to a broad audience, including physicians, pharmacists, nurses, other healthcare providers, ethicists, policy-makers, and legal experts interested in patient safety and healthcare quality. It should be available to everyone interested in the patient safety movement."

  --William R. Hendee, PhD
  Medical College of Wisconsin
  Doody's Review Service

  "The 69 international specialists who contribute to the Patient Safety Handbook offer practical guidance on implementing systems and processes to improve patient outcomes and advance patient safety. The handbook covers the full spectrum of patient safety and risk reduction, and discusses operational issues and the actual application of the principles of research, building upon the fundamentals of the science of safety...This book will find a place on the shelves of all health care sciences libraries..."

  --Mark Spasser
  Chief, Library and Information Services/Associate Professor
  Jewish Hospital College of Nursing and Allied Health Library
  E-Streams, Vol. 7, No. 5