2021_Book_TextbookOfPatientSafetyAndClin

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6 Patients for Patient Safety events, have the opportunity to actively collaborate in co-producing patient safety solutions. Those who have experienced adverse events identify gaps in safety and quality and offer wisdom, data, and stories unavailable through traditional sources. Each of these case studies illustrates the power and potential of coproduction with patients, families, and communities in research, medical professions education, healthcare quality improvement and policy. Each is different in scope, structure, and purpose and engage different stakeholders at different levels yet they all highlight the necessary building blocks for co-production of patient safety initiatives and each responds to the call made in the London Declaration, the WHO PFPS Programme, and the WHA to place patients at the center of efforts to improve patient safety. The building blocks include: 1. Dedicated, resilient patient, family, and community members who have directly or indirectly experienced unsafe care yet are willing to partner with healthcare decisionmakers and learn how to navigate the complexities, structures and limitations of different healthcare systems. They have become accomplished storytellers, networkers and connectors and have gained appreciation of the many challenges that healthcare providers and leaders face while remaining unwilling to accept the status quo. 2. Courageous, passionate healthcare leaders with the moral imperative to integrate the patient/citizen community into patient safety improvement efforts. These leaders are visionaries who visibly demonstrate their commitment to listen and learn from others. They value the input from others as highly as their own and integrate what they learn into governance, missions and strategies that promote patient involvement. They hard-wire the necessary resources to overcome political, cultural and financial barriers into budgets and infrastructures that support patient participation. 3. Capacity building opportunities 77 • for patients, families and communities to help them develop the skills to effectively share their personal stories of unsafe care that captures the hearts and minds, builds trust and prompts action from the audiences and to have productive dialogue with healthcare leaders including policy makers, researchers, medical educators and quality improvement experts, • for healthcare professionals and leaders to learn how to utilize effective patientcentered methods to collaborate, communicate with, listen to and engage with patients, families and community members in a democratic way. 4. Structure that establishes how patients, families and communities operate to obtain their goals. There is no one structure that is considered the gold standard for the organization of patients, families and communities. Structures may be formal or informal. Informal structures tend to be loosely organized, autonomous, volunteer patient networks that collaborate with healthcare professionals, leaders and organizations. More formal structures tend to be established patient organizations and associations which operate independently from the healthcare system or government such as civil society organizations. Finally, there are publicly funded structures that embed patients, family and community members into their strategic plans, budgets and activities necessary to achieve organizational goals. Whether formal or informal, it is essential that the structure preserves the values, preferences and outcomes that matter most to patients, families and communities and that these serve as overarching principles that guide the actions and priorities of the safety initiatives. It is also important that the structure facilitates access for patients, families and community members to healthcare decision-makers as well as financial and human resources to systematically analyze the outcomes of co-produced safety initiatives to improve, scale and spread, or disseminate the benefits of implementation and to ensure sustainability.
78 All stakeholders must accept, value, and support meaningful patient engagement in the coproduction of our efforts to improve patient safety including in the design of research, medical education, policy making, and healthcare organization quality improvement. We must continue to strive to democratize our healthcare. We “must have a powerful voice and role in the decisions and systems that affect… [our] health, and…[be given the] tools that help…[us] to become far more actively engaged…health professionals and institutions must value social equity and the individual in the context of community” [42]. I know this because I have lived it and witnessed the successes. References 1. Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 Sept 1978. 2. Flott K, Fontana G, Darzi A. The global state of patient safety. London: Imperial College London; 2019. 3. The World Health Assembly. Available at: https:// www.who.int/about/governance/world-health-assembly. Accessed 18 Dec 2019. 4. World Health Organisation (WHO). Resolution WHA 72.6: global action on patient safety. Geneva: WHO; 2019. 5. Ihi.org. About this IHI virtual expedition. 2019. Available at: http://www.ihi.org/education/ WebTraining/Expeditions/coproduction/Pages/ default.aspx. Accessed 17 Dec 2019. 6. Turakhia P, Combs B. Using principles of coproduction to improve patient care and enhance value. AMA J Ethics. 2017;19(11):1125–31. 7. World Health Organisation (WHO). World Health Assembly resolution WHA 55.18. Geneva: WHO; 2002. 8. World Alliance for Patient Safety. https://www.who. int/patientsafety/worldalliance/en/. Accessed 18 Dec 2019. 9. World Alliance for Patient Safety. Patients for Patient Safety. https://www.who.int/patientsafety/patients_ for_patient/regional_champions/en/. Accessed 18 Dec 2019. 10. World Health Organisation (WHO). Patients for Patient Safety: the London declaration. Geneva: WHO; 2006. 11. Woodgate RL, Zurba M, Tennent P. Advancing patient engagement: youth and family participation in health research communities of practice. Res Invol Engage. 2018;4:9. S. Sheridan et al. 12. pic-K. pic-K. Available at: https://pic-k.org/. Accessed 20 Dec 2019. 13. Johnson L, Bhutani V, Karp K, et al. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;29:S25–45. 14. Centers for Disease Control and Prevention. Jaundice and Kernicterus|CDC. Available at: https://www.cdc. gov/ncbddd/jaundice/index.html. Accessed 20 Dec 2019. 15. Maisels M, Bhutani V, Bogen D, Newman T, Stark A, Watchko J. Hyperbilirubinemia in the newborn infant >=35 weeks’ gestation: an update with clarifications. Pediatrics. 2009;124(4):1193–8. 16. Reliasmedia.com. JCAHO issues warning on kernicterus danger|2001-07-01|AHC Media: Continuing Medical Education Publishing. Available at: https:// www.reliasmedia.com/articles/71202-jcaho-issueswarning-on-kernicterus-danger. Accessed 20 Dec 2019. 17. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington, DC: The National Academies Press; 2015. 18. Society to Improve Diagnosis in Medicine. Available at: https://www.improvediagnosis.org/news_posts/ sidm-approved-for-a-250000-engagement-awardfrom-the-patient-centered-outcomes-research-institute/. Accessed 20 Dec 2019. 19. Society to Improve Diagnosis in Medicine. Disparities—society to improve diagnosis in medicine. Available at: https://www.improvediagnosis.org/ disparities/. Accessed 20 Dec 2019. 20. World Health Organisation (WHO). Patient engagement: technical series on safer primary care. Geneva: WHO; 2016. 21. Spencer J, Godolphin W, Karpenko N, Towle A. Can patients be teachers? Involving patients and service users in healthcare professionals’ education. Newcastle: The Health Foundation; 2011. 22. World Health Organisation (WHO). IBEAS: a pioneer study on patient safety in Latin America: towards safer hospital care. Geneva: WHO; 2011. 23. Vazquez Curiel E. WHO News Archive. Who. int. Available at: https://www.who.int/gpsc/news/ Evangelina-Vazquez-Curiel.pdf. Accessed 20 Dec 2019. 24. Allegranzi B, Storr J, Dziekan G, et al. The first global patient safety challenge “Clean care is safer care”: from launch to current progress and achievements. J Hosp Infect. 2007;65(Suppl. 2):115–23. 25. World Alliance for Patient Safety. The second global patient safety challenge: safe surgery saves lives. Geneva: World Health Organization; 2008. 26. Donaldson LJ, Kelley ET, Dhingra-Kumar N, Kieny M-P, Sheikh A. Medication without harm: WHO’s third global patient safety challenge. Lancet. 2017;389(10080):1680. 27. Gomez A. PAHO/WHO|PAHO Today, December 2008 Edition—Patient Champions Launch New Advocacy Network. Pan
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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Page 43 and 44: 32 • A routine violation is basic
Page 45 and 46: 34 Table 3.1 Framework of contribut
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Page 57 and 58: 46 ment of theories on how to deliv
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Page 63 and 64: 52 15. National Academies of Scienc
Page 65 and 66: 54 In this chapter, I will reflect
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Page 73 and 74: 62 health. It is hoped that the Che
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Page 77 and 78: 66 21. World Alliance for Patient S
Page 79 and 80: 68 death of my late husband, Pat, f
Page 81 and 82: 70 S. Sheridan et al. test. A separ
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Page 125 and 126: The Patient Journey Elena Beleffi,
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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30 Non-technical Skills in Healthca
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Medication Safety Hooi Cheng Soon,
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31 Medication Safety • Be familia
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31 Medication Safety 439 Table 31.1
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31 Medication Safety to be made bet
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31 Medication Safety medication reg
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31 Medication Safety and contexts,
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31 Medication Safety quently when m
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31 Medication Safety 31.5 Final Rec
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31 Medication Safety 451 ity and im
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31 Medication Safety 453 Open Acces
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456 studies in recent years have hi
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458 F. Ranzani and O. Parlangeli in
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460 Any difficulty encountered by t
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462 32.4.2 The Usability Assessment
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464 23. Parlangeli O, Mengoni G, Gu
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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