Error Reduction in Health Care

Patrice L. Spath, MA, RHIT, is president of Brown-Spath & Associates and assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham. She serves on the advisory board for WebM&M, an online case-based journal and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research and Quality. Spath has authored numerous books and journal articles on health care performance improvement and patient safety.

• Figures, Tables, and Exhibits vForeword ixLucian L. LeapePreface xiThe Editor xviiThe Authors xixPART ONE: The Basics of Patient SafetyChapter 1 A Formula for Errors: Good People + Bad Systems 3Susan McClanahan, Susan T. Goodwin, and Jonathan B. PerlinChapter 2 The Human Side of Medical Mistakes 21Sven TernovChapter 3 High Reliability and Patient Safety 35Yosef D. Dlugacz and Patrice L. SpathPART TWO: Measure and Evaluate Patient SafetyChapter 4 Measuring Patient Safety Performance 59Karen Ferraco and Patrice L. SpathChapter 5 Analyzing Patient Safety Performance 103Karen Ferraco and Patrice L. SpathChapter 6 Using Performance Data to Prioritize Safety Improvement Projects 119Robert LatinoPART THREE: Reactive and Proactive Safety InvestigationsChapter 7 Accident Investigation and Anticipatory Failure Analysis 143Sanford E. Feldman and Douglas W. RoblinChapter 8 MTO and DEB Analysis Can Find System Breakdowns 157Sven TernovChapter 9 Using Deductive Analysis to Examine Adverse Events 171Robert LatinoPART FOUR: How to Make Health Care Processes SaferChapter 10 Proactively Error-Proofing Health Care Processes 197Richard J. Croteau and Paul M. SchyveChapter 11 Reducing Errors Through Work System Improvements 217Patrice L. SpathChapter 12 Improve Patient Safety with Lean Techniques 245Danielle LavalleePART FIVE: Focused Patient Safety InitiativesChapter 13 How Information Technology Can Improve Patient Safety 269Donna J. Slovensky and Nir MenachemiChapter 14 A Structured Teamwork System to Reduce Clinical Errors 297Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. MoreyChapter 15 Medication Safety Improvement 335Yosef D. DlugaczGlossary 369Index 383