To Do No Harm: Ensuring Patient Safety in Health Care Organizations (J-B AHA Press)

386 Pages·2004·4.5 MB·English

by  Julianne M.

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Y
TO DO NO HARM
Ensuring Patient Safety in
Health Care Organizations
Julianne M. Morath
Joanne E. Turnbull
Foreword by Lucian L. Leape
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TO DO NO HARM
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Y
TO DO NO HARM
Ensuring Patient Safety in
Health Care Organizations
Julianne M. Morath
Joanne E. Turnbull
Foreword by Lucian L. Leape
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Copyright © 2005 by John Wiley & Sons,Inc.All rights reserved.
Published by Jossey-Bass
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may not be available in electronic books.
The WalkRounds questions listed on p.19 are © Joint Commission Resources:Jt Comm J Qual Safe.
Oakbrook Terrace,IL:Joint Commission on Accreditation of Healthcare Organizations,2003,18.
Reprinted with permission.
The excerpt on pp.186–187 by DonaldBerwick is copyright 1996,BMJ Publishing Group.Reprinted
with permission.
The excerpt on p.198 by Valerie Reitman is copyright 2003,Los Angeles Times.Reprinted with
permission.
Library of Congress Cataloging-in-Publication Data
Morath,Julianne M.
To do no harm :ensuring patient safety in health care organizations / Julianne M.Morath,
Joanne E.Turnbull ;foreword by Lucian L.Leape.— 1st ed.
p.;cm.
Includes bibliographical references.
ISBN 0-7879-6770-X (alk.paper)
1. Medical errors—Prevention. 2. Health facilities. [DNLM:1. Medical Errors—prevention &
control. 2. Safety Management—organization & administration. 3. Health Facilities—organization
& administration. 4. Organizational Innovation. 5. Truth Disclosure. WX 185 M831t 2004]
I. Turnbull, Joanne E. II. Title.
R729.8.M665 2004
362.1—dc22 2004002758
Printed in the United States of America
FIRSTEDITION
HB Printing 10 9 8 7 6 5 4 3 2 1
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CONTENTS
Foreword ix
Lucian L. Leape
Preface xv
Acknowledgments xxiii
The Authors xxvii
Introduction 1
1 Declare Patient Safety Urgent and a Priority 12
2 Error and Harm in Health Care 23
3 Understanding the Basics of Patient Safety 44
4 Assume Executive Responsibility 71
5 Import New Knowledge and Skills 96
6 Install a Blameless Reporting System 120
7 Assign Accountability 148
8 Align External Controls and Reform Education 181
vii
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viii Contents
9 Accelerate Change For Improvement 204
10 The End of the Beginning 234
References 245
Glossary 255
Appendixes
1 Checklist for Assessing Institutional Resilience 279
2 Creating De-Identified Case Studies for Dissemination 283
3 Medical Accidents Policy: Reporting and Disclosure,
Including Sentinel Events 285
4 Medication Safety Team Feedback Form 295
5 Patient Safety Workplan 297
6 Safety Learning Report 300
7 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 303
8 Complexity Lens Reflection 308
9 A Brief Look at Gaps in the Continuity of Care 311
10 A Brief Look at the New Look in Complex System Failure, Error, and Safety 313
11 A Reminder on Every Chart 315
12 List of Serious Reportable Events inHealth Care 316
13 Statement of Principle: Talking to Patients About Health Care Injury 321
14 VHA Patient Safety Organizational Assessment 322
Additional Readings 331
Resources 335
Index 345