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Case Studies in Patient Safety
Foundations for Core Competencies

Author(s): Julie K. Johnson, MSPH, PhD, Professor, Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine Northwestern University, Chicago, Illinois
Helen W. Haskell, MA, President, Mothers Against Medical Error, Columbia, South Carolina
Paul R. Barach, MD, MPH, Guest Professor, School of Medicine, University of Oslo, Oslo, Norway
Details:
  • ISBN-13: 9781449681548
  • Paperback    342 pages      © 2016
Price: $79.95 US List
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This unique compendium of case studies on patient safety – told from the perspective of the patient and family – illustrates 24 stories of preventable health care errors that led to irreparable patient harm.  The reader is guided through a structured analysis of the events, eliciting lessons learned and strategies for preventing similar events in the future.  Learning objectives for each case facilitate the reader’s development of a set of core competencies related to improving safety and quality of health care.

Students of the health professions including medicine, nursing, pharmacy, health administration, public health, as well as practicing professionals such as patient safety officers, chief quality officers, risk managers, and health service researchers will gain valuable insight into the real-world of medical errors and a better understanding of how they can be prevented through practical, actionable methods.

Dedication
Acknowledgements  
Foreword  
Preface  
Introduction  
  Section  1  PATIENT CARE
    Case  1  It’s Hard to Kill a Healthy 15-year-old The Story of Lewis Blackman (United States)
    Case  2  A Routine Appendectomy The Story of John (Australia)
    Case  3  The Origins of the Mid Staffordshire Inquiry into the National Health Service The Story of Bella Bailey (United Kingdom)
    Case  4  Consent and Disclosure in Pediatric Heart Surgery The Story of James Mannix (United States)
  Section  2  KNOWLEDGE FOR PRACTICE
    Case  5  I'm Left in Fear: An Account of Harm in Maternity Care The Story of Amelia (United Kingdom)
    Case  6  A Routine Endoscopic Procedure The Story of Dorothy Johnson (United States)
    Case  7  The Last Run: An Undiagnosed Heart Rhythm Disturbance The Story of Alex James (United States)
  Section  3  PRACTICE-BASED LEARNING AND IMPROVEMENT
    Case  8  Improving Care for People with Intellectual Disability The Story of Andy (Australia)
    Case  9  A Cascade of Small Events: Learning from an Unexpected Post-Surgical Death The Story of Nick Francis (Canada)
    Case  10  Accidental Fall in a Hospital The Story of Colin Lake (Australia)
  Section  4  INTERPERSONAL AND COMMUNICATION SKILLS
    Case  11  Not Considered a Partner: A Mother’s Story of a Tonsillectomy Gone Wrong The Story of Noah Lord (United States)
    Case  12  Lost: A Patient’s Search for Answers for Intractable Pain The Story of Claudine Goze-Weber (France)
    Case  13  The Silence of the Hospital: Lessons on Supporting Patients and Staff after An Adverse Event The Story of Linda Kenney (United States)
  Section  5  PROFESSIONALISM
    Case  14  The Big Picture: A Terminally Ill Patient in a Fragmented System The Story of Fred Holliday (United States)
    Case  15  Without a Heart: The Legal Sequelae of an Unexplained Hospital Death The Story of Jerry Carswell (United States)
    Case  16  Small Steps: From Medication Adjustment to Permanent Disability The Story of Rita Hooper Washington (United States)
    Case  17  The Definition of Alive: The Story of an Equivocal Birth The Story of Paris Humphrey (United States)
  Section  6  SYSTEMS-BASED PRACTICE
    Case  18  Not for IV Use: The Story of An Enteral Tubing Misconnection The Story of Robin and Addison Lowe (United States)
    Case  19  Death Despite Known Drug Allergy The Story of Zoya (Australia)
    Case  20  The Trial Meant for You: The Lifelong Medical Journey of a Child with a Complex Congenital Condition The Story of Kirsten Morrise (United States)
  Section  7  INTERPROFESSIONAL COLLABORATION
    Case  21  Failure to Rescue The Story of DJ Sterner (United States)
    Case  22  Unmonitored: A Post-Surgical Narcotic Overdose in the Hospital The Story of Louise Batz (United States)
    Case  23  The Voice that is Missing: A Mother’s Journey in Patient Safety Advocacy The Story of Michael Corina (United States)
    Case  24  When Healing Harms: Recovering from a Multi-System Traumatic Injury The Story of Kathy Torpie (New Zealand)
  Section  8  PERSONAL AND PROFESSIONAL DEVELOPMENT
Afterword  Personal and Professional Development
Appendix  Recommended List of Core Competencies for Health Professions
Index  

Julie K. Johnson, MSPH, PhD-Professor, Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine Northwestern University, Chicago, Illinois

Helen W. Haskell, MA-President, Mothers Against Medical Error, Columbia, South Carolina

Paul R. Barach, MD, MPH-Guest Professor, School of Medicine, University of Oslo, Oslo, Norway

  • Front Matter
    Front Matter
  • Case 1
    It’s Hard to Kill a Healthy 15-year-old The Story of Lewis Blackman