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Contents

SECTION I: AN INTRODUCTION TO PATIENT SAFETY AND MEDICAL ERRORS Chapter 1 - New ways of detecting errors, including Trigger Tools and electronic methods of monitoring - New measures of patient safety - Safety rating systems The Nature and Frequency of Medical Errors and Adverse Events Adverse Events, Preventable Adverse Events, and Errors The Challenges of Measuring Errors and Safety The Frequency and Impact of Errors Key Points References and Additional Readings Chapter 2 Basic Principles of Patient Safety The Modern Approach to Patient Safety: Systems Thinking and the Swiss Cheese Model Errors at the Sharp End: Slips versus Mistakes Complexity Theory and Complex Adaptive Systems General Principles of Patient Safety Improvement Strategies Key Points References and Additional Readings Chapter 3 - Challenges in prioritizing patient safety given the increased pressure to decrease waste, and improve value, patient experience and access Safety, Quality, and Value What is Quality? The Epidemiology of Quality Problems Catalysts for Quality Improvement The Changing Quality Landscape Quality Improvement Strategies Commonalities and Differences Between Quality and Patient Safety Value: Connecting Quality (and Safety) to the Cost of Care Key Points References and Additional Readings SECTION II: TYPES OF MEDICAL ERRORS Chapter 4 Medication Errors Some Basic Concepts, Terms, and Epidemiology Strategies to Decrease Medication Errors Key Points References and Additional Readings Chapter 5 - Procedural safety, including role of video review and simulators Surgical Errors Some Basic Concepts and Terms Volume-Outcome Relationships Patient Safety in Anesthesia Wrong-Site/Wrong-Patient Surgery Retained Sponges and Instruments Surgical Fires Safety in Nonsurgical Bedside Procedures Key Points References and Additional Readings Chapter 6 - Update on diagnostic errors (in light of a 2015 IOM report) Diagnostic Errors Some Basic Concepts and Terms Missed Myocardial Infarction: A Classic Diagnostic Error Cognitive Errors: Iterative Hypothesis Testing, Bayesian Reasoning, and Heuristics Improving Diagnostic Reasoning Communication and Information Flow Issues in Diagnostic Errors Overdiagnosis The Policy Context for Diagnostic Errors Key Points References and Additional Readings Chapter 7 Human Factors and Errors at the Person-Machine Interface Introduction Human Factors Engineering Usability Testing and Heuristic Analysis Applying Human Factors Engineering Principles Key Points References and Additional Readings Chapter 8 - Better understanding of the challenges of handoffs and signouts, new best practices Transition and Handoff Errors Some Basic Concepts and Terms Best Practices for Person-to-Person Handoffs Site-to-Site Handoffs: The Role of the System Best Practices for Site-to-Site Handoffs Other Than Hospital Discharge Preventing Readmissions: Best Practices for Hospital Discharge Key Points References and Additional Readings Chapter 9 Teamwork and Communication Errors Some Basic Concepts and Terms The Role of Teamwork in Healthcare Fixed Versus Fluid Teams Teamwork and Communication Strategies Key Points References and Additional Readings Chapter 10 Healthcare-Associated Infections General Concepts and Epidemiology Surgical Site Infections Ventilator-Associated Pneumonia Central Line-Associated Bloodstream Infections Catheter-Associated Urinary Tract Infections Methicillin-Resistant S. Aureus Infection C. Difficile Infection What Can Patient Safety Learn from the Approach to Hospital-Associated Infections Key Points References and Additional Readings Chapter 11 - Post-hospital syndrome Other Complications of Healthcare General Concepts Venous Thromboembolism Prophylaxis Preventing Pressure Ulcers Preventing Falls Preventing Delirium Key Points References and Additional Readings Chapter 12 - Increased emphasis on safety in ambulatory and non-hospital settings Patient Safety in the Ambulatory Setting General Concepts and Epidemiology Hospital Versus Ambulatory Environments Improving Ambulatory Safety Key Points References and Additional Readings SECTION III: SOLUTIONS Chapter 13 - CPOE and EHRs: more on unanticipated consequences (new kinds of errors, alert fatigue), lack of interoperability Information Technology Healthcare's Information Problem Electronic Health Records Computerized Provider Order Entry Other IT-Related Safety Solutions Computerized Clinical Decision Support Systems IT Solutions for Improving Diagnostic Accuracy The Policy Environment for HIT Key Points References and Additional Readings Chapter 14 - Rethinking root cause analysis Reporting Systems, Root Cause Analysis, and Other Methods of Understanding Safety Issues Overview General Characteristics of Reporting Systems Hospital Incident Reporting Systems The Aviation Safety Reporting System Reports to Entities Outside the Healthcare Organization Patient Safety Organizations Root Cause Analysis and Other Incident Investigation Methods Morbidity and Mortality Conferences Other Methods of Capturing Safety Problems Key Points References and Additional Readings Chapter 15 - Update on checklists Creating a Culture of Safety Overview An Illustrative Case Measuring Safety Culture Hierarchies, Speaking Up, and the Culture of Low Expectations Production Pressures Teamwork Training Checklists and Culture Rules, Rule Violations, and Workarounds Some Final Thoughts on Safety Culture Key Points References and Additional Readings Chapter 16 - Workforce issues and clinician burnout Workforce Issues Overview Nursing Workforce Issues Rapid Response Teams House Staff Duty Hours The "July Effect" Nights and Weekends "Second Victims": Supporting Caregivers After Major Errors Key Points References and Additional Readings Chapter 17 - Safety and medical education (including impact of 2011 duty hours reform and new ACGME patient safety assessment) Education and Training Issues Overview Autonomy Versus Oversight Simulation Training Teaching Patient Safety Key Points References and Additional Readings Chapter 18 The Malpractice System Overview Tort Law and the Malpractice System Error Disclosure, Apologies, and Malpractice No-Fault Systems and "Health Courts": An Alternative to Tort-Based Medical Malpractice Cases as a Source of Safety Lessons Key Points References and Additional Readings Chapter 19 Accountability Overview Accountability Disruptive Providers The "Just Culture" Reconciling "No Blame" and Accountability The Role of the Media Key Points References and Additional Readings Chapter 20 - Impact of major policy initiatives, including the Affordable Care Act and the Partnership for Patients Accreditation and Regulations Overview Accreditation Regulations Other Levers to Promote Safety P roblems with Regulatory, Accreditation, and Other Prescriptive Solutions Key Points References and Additional Readings Chapter 21 The Role of Patients Overview Patients with Limited English Proficiency Patients with Low Health Literacy Errors Caused by Patients Themselves Patient Engagement as a Safety Strategy Key Points References and Additional Readings Chapter 22 - Learning healthcare systems Organizing a Safety Program Overview Structure and Function Managing the Incident Reporting System Dealing with Data Strategies to Connect Senior Leadership with Frontline Personnel Strategies to Generate Frontline Activity to Improve Safety Dealing with Major Errors and Sentinel Events Failure Mode and Effects Analyses Qualifications and Training of the Patient Safety Officer The Role of the Patient Safety Committee Engaging Physicians in Patient Safety Board Engagement in Patient Safety Research in Patient Safety Patient Safety Meets Evidence-Based Medicine Key Points References and Additional Readings Conclusion SECTION IV: APPENDICES Appendix I. Key Books, Reports, Series, and Web Sites on Patient Safety Appendix II. The AHRQ Patient Safety Network (AHRQ PSNet) Glossary of Selected Terms in Patient Safety Appendix III. Selected Milestones in the Field of Patient Safety Appendix IV. The Joint Commission's National Patient Safety Goals (Hospital Version, 2011) Appendix V. Agency for Healthcare Research and Quality's (AHRQ) Patient Safety Indicators (PSIs) Appendix VI. The National Quality Forum's List of Serious Reportable Events, Appendix VII. The National Quality Forum's List of "Safe Practices for Better Healthcare-2010 Update" Appendix VIII. Medicare's "No Pay for Errors" List Appendix IX. Things Patients and Families Can Do, and Questions They Can Ask, to Improve Their Chances of Remaining Safe in the Hospital Index

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