2021_Book_TextbookOfPatientSafetyAndClin

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viii Preface facilities and care homes in many countries. We have added a chapter that summarizes the safety recommendations developed by the International Society for Quality in Health Care in collaboration with the Italian Network for Safety in Healthcare. It is encouraging also to see that World Patient Safety Day 2020 had as its theme health worker safety, which, of course, is closely intertwined with patient safety. We are grateful for the support of the Fondazione Italia in Salute (Healthy Italy Foundation) to allow this text to be open access in order to be available to the greatest number of interested people. We hope to see it in the hands of young health professionals everywhere, thus giving it a global reach into the next generation of patient safety clinical leaders and practitioners. We express our deep gratitude to the authors for their work. We also thank those many friends and colleagues who have made themselves available to review the chapters from a technical and linguistic point of view. We dedicate our work on this book to the memories of all those patients and families who have suffered or died through avoidable harm in their care. It is on the foundation of a safer future for all patients, everywhere in the world, that the goal of universal health coverage should be built. London, UK Rome, Italy Evanston, USA Florence, Italy Liam Donaldson Walter Ricciardi Susan Sheridan Riccardo Tartaglia
Acknowledgements The volume editors wish to thank the following colleagues and friends for the chapters review and for their collaboration to the book preparation: –– Sebastiano Bagnara, Psychologist, Florence, Italy –– Luigi Bertinato, Istituto Superiore di Sanità, Rome, Italy –– Gianni Biancofiore, Intensive care, University of Pisa, Italy –– Stefano Canitano, Radiology, San Camillo de Lellis Rieti, Italy –– Claudio Cricelli, Primary care, Italian Society General Medicine, Italy –– Alessandro Dell’Erba, Forensic Medicine University of Bari, Italy –– Davide Ferorelli, Forensic Medicine University of Bari, Italy –– Alessandra De Palma, Forensic Medicine, IRCS AOU, Bologna –– Enrico Desideri, Public Health, Fondazione Innovazione e Sicurezza delle Cure, Rome, Italy –– Vittorio Fineschi, Forensic Medicine, University La Sapienza, Rome, Italy –– Paola Frati, Forensic Medicine, University La Sapienza, Rome, Italy –– Georgia Libera Finstad, Psychological sciences and techniques, Rome, Italy –– Maurizio Hazan, Lawyer, Milan, Italy –– Roberto Nardi, Internal Medicine, Bologna, Italy –– Patrizia Olmi, Radiotherapist, Florence, Italy –– Maria Pia Ruggeri, Emergency Medicine, Azienda Ospedaliera San Giovanni-Addolorata-Britannico, Rome, Italy –– Anna Maria Marconi, Gynaecologist, University of Milan, Italy –– Chiara Seghieri, Statistic, School of Advanced Study Pisa, Italy –– Andrea Silenzi, General Directorate for Health Prevention, Ministry of Health, Rome The volume editors also wish to express their thanks for the linguistic revision to: –– Roland Bauman –– Liisa Dollinger –– Lucrezia Romano ix
Page 1 and 2: Textbook of Patient Safety and Clin
Page 3 and 4: Liam Donaldson • Walter Ricciardi
Page 5 and 6: Foreword As a member of the 17th le
Page 7: Preface Despite the extensive atten
Page 11 and 12: xii Contents 11 Adverse Event Inves
Page 13 and 14: Part I Introduction
Page 15 and 16: 4 explain how to prepare and update
Page 17 and 18: 6 considered preventable) [11]. Fur
Page 19 and 20: 8 W. Ricciardi and F. Cascini the l
Page 21 and 22: 10 W. Ricciardi and F. Cascini inte
Page 23 and 24: 12 maximized or perhaps even realiz
Page 25 and 26: 14 steps in obtaining, managing, an
Page 27 and 28: 16 quality improvement methodologie
Page 29 and 30: 18 99. Morciano C, et al. Policies
Page 31 and 32: 20 Reason travelled the world makin
Page 33 and 34: 22 For each hospital unit, other do
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Page 37 and 38: 26 R. Tartaglia Table 2.1 Differenc
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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 53 and 54: 42 assessment and prevention was no
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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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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