Patient Safety And Serious Incident Responses
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| Author | : Alison Elliott |
| Publisher | : Taylor & Francis |
| Total Pages | : 212 |
| Release | : 2024-09-30 |
| Genre | : Medical |
| ISBN | : 1040120695 |
This step-by-step guide takes the reader through the complex process of investigating serious incidents in health, social care, and criminal justice environments, acknowledging differences of culture and context that shape an investigation. Taking a multi-disciplinary approach, Part 1 begins by exploring the key principles of investigation, including ethical and legal perspectives, the involvement of families and carers, and being aware of unconscious bias, among other issues. Part 2 outlines in detail the conduct of investigations, from planning to processing the findings, before moving on to Part 3, carrying them out in diverse settings. Further chapters then look at investigating within diverse environments before moving on to to Part 4 which deals with reviewing and analysing the evidence collected and writing up the investigation. This final part also examines the pivotal issue of learning from the investigation and disseminating the report. The inclusion of case studies, models of good practice, and vignettes enables the reader to view each stage of the process in context and drive the transformation of practice. This practical resource is designed to support health and social care professionals who undertake investigations as part of their role, including nurses, allied health practitioners, social workers, doctors, and psychologists, as well as military personnel and law enforcers. It is an essential companion.
| Author | : Russell Kelsey |
| Publisher | : CRC Press |
| Total Pages | : 229 |
| Release | : 2023-08-28 |
| Genre | : Law |
| ISBN | : 1000913694 |
The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.
| Author | : Ronda Hughes |
| Publisher | : Department of Health and Human Services |
| Total Pages | : 592 |
| Release | : 2008 |
| Genre | : Medical |
| ISBN | : |
"Nurses play a vital role in improving the safety and quality of patient car -- not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes. To address this need, the Agency for Healthcare Research and Quality (AHRQ), with additional funding from the Robert Wood Johnson Foundation, has prepared this comprehensive, 1,400-page, handbook for nurses on patient safety and quality -- Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (AHRQ Publication No. 08-0043)." - online AHRQ blurb, http://www.ahrq.gov/qual/nurseshdbk/
| Author | : Kerm Henriksen |
| Publisher | : |
| Total Pages | : 526 |
| Release | : 2005 |
| Genre | : Medical |
| ISBN | : |
v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.
| Author | : Institute of Medicine |
| Publisher | : National Academies Press |
| Total Pages | : 485 |
| Release | : 2004-03-27 |
| Genre | : Medical |
| ISBN | : 0309187362 |
Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
| Author | : Institute of Medicine |
| Publisher | : National Academies Press |
| Total Pages | : 312 |
| Release | : 2000-03-01 |
| Genre | : Medical |
| ISBN | : 0309068371 |
Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine
| Author | : Lucian L. Leape |
| Publisher | : Springer Nature |
| Total Pages | : 450 |
| Release | : 2021-05-28 |
| Genre | : Medical |
| ISBN | : 3030711234 |
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
| Author | : Russell Kelsey |
| Publisher | : CRC Press |
| Total Pages | : 169 |
| Release | : 2016-11-30 |
| Genre | : Law |
| ISBN | : 1315349507 |
At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
| Author | : Liam Donaldson |
| Publisher | : Springer Nature |
| Total Pages | : 496 |
| Release | : 2020-12-14 |
| Genre | : Medical |
| ISBN | : 3030594033 |
Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems. The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties. This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.
| Author | : Sonia Macleod |
| Publisher | : Bloomsbury Publishing |
| Total Pages | : 321 |
| Release | : 2023-01-12 |
| Genre | : Law |
| ISBN | : 1509916679 |
This book explores how concerns can be raised about the NHS, why raising concerns hasn't always improved standards, and how a no-fault open culture approach could drive improvements. The book describes a wide range of mechanisms for raising concerns about the NHS, including complaints, the ombudsman, litigation, HSIB, and the major inquiries since 2000, across the various UK jurisdictions. The NHS approach is contextualised within the broader societal developments in dispute resolution, accountability, and regulation. The authors take a holistic view, and outline practical solutions for reforming how the NHS responds to problems. These should improve the situation for those raising concerns and for those working within the NHS, as well as providing cost savings. The no-fault approaches proposed in the book provide long-term sustainable solutions to systemic problems, which are particularly timely given the impact of the COVID-19 pandemic on the NHS. The book will be of interest to academics, researchers, ADR practitioners, practising lawyers, and policy makers.
