2021_Book_TextbookOfPatientSafetyAndClin

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6 Patients for Patient Safety American Health Organization/World Health Organization. 2019. Available at: https:// www.paho.org/hq/index.php?option=com_ content&view=article&id=585:2009-patient-champions-launch-new-advocacy-network&Itemid=406 23&lang=en. Accessed 18 Dec 2019. 28. Patientsikkerhed. The Danish Society for Patient Safety. Available at: https://patientsikkerhed.dk/ om-os/. Accessed 20 Dec 2019. 29. Patientsikkerhed. Danish presentations and experience days: A8: The Danish Way: teaching doctors to listen. Live patient storytelling in communication skills courses. Available at: https://patientsikkerhed. dk/internationalforum2020/danske-oplaeg/. Accessed 20 Dec 2019. 30. Psnet.ahrq.gov. Patient Engagement and Safety|PSNet. Available at: https://psnet.ahrq.gov/primer/patientengagement-and-safety. Accessed 18 Dec 2019. 31. Metwally, N. Towards building capacity in patients and empowering patient voices in Egypt. 2018. 32. Event.icebergevents.com.au. Nagwa Metwally, Egypt—Speakers|World Hospital Congress. Available at: https://event.icebergevents.com.au/whc2018/ speakers/nagwa-metwally-egypt. Accessed 20 Dec 2019. 33. Carinci F, Labella B, Cardinali F, Carzaniga S, Cerilli M, Duranti G, Lamanna A, Raho V, Caracci G. A National Program to improve person centeredness in hospital through a partnership with citizens. Eur J Pub Health. 2018;28(4) https://doi.org/10.1093/eurpub/ cky214.178. Accessed 20 Dec 2019. 34. Patientsafetyinstitute.ca. Patients for Patient Safety Canada. Available at: https://www.patientsafetyinstitute.ca/en/About/Programs/ppsc/Pages/default.aspx. Accessed 18 Dec 2019. 35. Patientsafetyinstitute.ca. About CPSI. Available at: https://www.patientsafetyinstitute.ca/en/About/ Pages/default.aspx. Accessed 18 Dec 2019. 36. Patientsafetyinstitute.ca. Canadian Disclosure Guidelines: being open with patients and families. 79 2011. Available at: https://www.patientsafetyinstitute. ca/en/toolsresources/disclosure/pages/default.aspx. Accessed 20 Dec 2019. 37. Patientsafetyinstitute.ca. Canadian incident analysis framework. 2012. Available at: https://www. patientsafetyinstitute.ca/en/toolsResources/ IncidentAnalysis/Documents/Canadian Incident Analysis Framework.PDF. Accessed 20 Dec 2019. 38. Patientsafetyinstitute.ca. The engaging patients in patient safety—a Canadian Guide. 2018. Available at: https://www.patientsafetyinstitute.ca/en/tool- sResources/Patient-Engagement-in-Patient-Safety- Guide/Documents/Engaging Patients in Patient Safety.pdf. Accessed 20 Dec 2019. 39. Patientsafetyinstitute.ca. Five questions to ask about your medications. Available at: http://www.patientsafetyinstitute.ca/en/toolsResources/5-Questionsto-Ask-about-your-Medications/Pages/default.aspx. Accessed 20 Dec 2019. 40. Patientsafetyinstitute.ca. Canadian quality and patient safety framework for health and social services. 2019. Available at: https://www. patientsafetyinstitute.ca/en/toolsResources/ Canadian-Quality-and-Patient-Safety-Frameworkfor-Health-and-Social-Services/Pages/default.aspx. Accessed 18 Dec 2019. 41. Girard-Griffith F. CPSI-HSO quality and patient safety framework for health and social services public online focus group consultation interview with the Patient Partner Network by conducted by Compass Rose. 2019. 42. Tang PC, Smith MD, Adler-Milstein J, Delbanco T, Downs SJ, Mallya GG, Ness DL, Parker RM, Sands DZ. The democratization of health care: a vital direction for health and health care. NAM perspectives. Discussion paper. Washington, DC: National Academy of Medicine; 2016. Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents 7 Pascale Carayon, Peter Kleinschmidt, Bat- Zion Hose, and Megan Salwei 7.1 Introduction Health care is about people with various roles (e.g., patient, caregiver, clinician) who interact and collaborate in connected care processes of diagnosis, treatment, monitoring, and management. Ensuring that these processes produce “good” outcomes for patients (e.g., quality of care, patient safety, positive patient experience) as well as for clinicians involved in their care (e.g., quality of working life of clinicians) remains a major challenge around the world. The US National Academies’ report on Crossing the Global Quality Chasm [1] indicates that inappropriate and unsafe care remain widespread around the world. In particular, “between 5.7 and 8.4 million deaths occur annually from poor quality of care in LMICs for … selected set of conditions …, which represents between 10% and 15% of the total deaths in LMICs … in 2015” (page S-2). P. Carayon (*) Department of Industrial and Systems Engineering, Wisconsin Institute of Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA e-mail: pcarayon@wisc.edu P. Kleinschmidt UW Health, Madison, WI, USA e-mail: PKleinschmidt@uwhealth.org B.-Z. Hose · M. Salwei University of Wisconsin-Madison, Madison, WI, USA e-mail: bhose@wisc.edu; msalwei@wisc.edu Two other reports also published in 2018 draw attention to patient safety challenges and gaps in health care quality around the world [2]. Systems approaches have been recommended to address these complex health care quality and patient safety problems [1, 3], as well as to improve work systems and working conditions for clinicians [4]. The discipline of human factors (or ergonomics) (HFE) provides systems concepts and methods to improve care processes and outcomes for patients, caregivers, and clinicians. According to the International Ergonomics Association, HFE is “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance” [5]. According to this definition of HFE by the IEA, people are at the center of (work) systems; systems and their elements and interactions should be designed to support performance and enhance well-being of people. HFE emphasizes the physical, cognitive, and organizational dimensions of work systems. Medical residents are key stakeholders in delivery of high-quality, safe care; they are often at the center of work systems that deliver care to patients in hospitals, primary care or specialty care facilities, emergency departments, and other care settings. Therefore, it is important to design the work system of medical residents to improve © The Author(s) <strong>2021</strong> L. Donaldson et al. (eds.), Textbook of Patient Safety and Clinical Risk Management, https://doi.org/10.1007/978-3-030-59403-9_7 81
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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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26 R. Tartaglia Table 2.1 Differenc
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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 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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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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