The Essentials of Patient Safety - Clinical Human Factors Group

More documents

Recommendations

Info

The Essentials of Patient Safety KEY POINTS Adverse events are injuries that are due to healthcare management rather than to the underlying disease Adverse events may or may not be preventable Studies of medical records in many countries suggest that 8-12% of hospitalised patients suffer one or more adverse events Older people are particularly vulnerable to harm from healthcare Voluntary reporting systems are poor at measuring adverse events but useful for learning about the vulnerabilities of healthcare systems References 1. Cook RI, Woods DD, Miller CA. A tale of two stories: contrasting views of patient safety, US National Patient Safety Foundation; 1998. 2. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety - An elusive target. Journal of the American Medical Association, 2006;296(6):696-9. 3. Brennan TA, Localio AR, Leape LL, Laird NM, Peterson L, Hiatt HH, et al. Identification of adverse events occurring during hospitalization. A cross-sectional study of litigation, quality assurance and medical records of two teaching hospitals. Annals of Internal Medicine, 1990;112(3):221-6. 4. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients; Results from the Harvard Medical Practice Study I. New England Journal of Medicine, 1991;324(6):370-6. 5. Neale G, Woloshynowych M. Retrospective case record review: a blunt instrument that needs sharpening. Quality and Safety in Health Care, 2003;12(1):2-3. 6. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care, 2008;17(3):216-23. 7. Davis P. Health care as a risk factor. Canadian Medical Association Journal, 2004;170(11):1688-9. 8. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Annals of Surgery, 2004;239(4):475-82. 9. Burke JP. Infection Control A Problem for Patient Safety. The New England Journal of Medicine, 2003;348(7):651-6. 16
The Essentials of Patient Safety 10. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, et al. Adverse drug events in ambulatory care. New England Journal of Medicine, 2003;348(16):1556-64. 11. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal, 2001;322(7285):517-9. 12. Kohn L, Corrigan J, Donaldson ME. To err is human, Washington DC: National Academy Press; 1999. 13. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Quality and Safety in Health Care, 2009;18(4):297-302. 14. Vincent C. Understanding and responding to adverse events. New England Journal of Medicine, 2003;348(11):1051-6. 15. Tsilimingras D, Rosen AK, Berlowitz DR. Patient safety in geriatrics: A call for action. Journals of Gerontology, 2003;58(9):813-9. 16. Oliver D. 'Acopia' and 'social admission' are not diagnoses: why older people deserve better. Journal of the Royal Society Medicine, 2008;101(4):168-74. 17. Long S. Adverse events in the care of the elderly (Unpublished PhD thesis). 2010. 18. Barach P, Small SD. Reporting and preventing mdeical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal, 2000;320(7237): 759-63. 19. Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Quality and Safety in Health Care, 2006;15(suppl_1):i82-i90. 20. Vincent C. Incident reporting and patient safety. British Medical Journal, 2007;334(7584):51. 21. Sari AB-A, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. British Medical Journal, 2007;334(7584):79. 17
Page 1 and 2: The Essentials of Patient Safety Th
Page 3 and 4: The Essentials of Patient Safety Co
Page 5 and 6: The Essentials of Patient Safety Bo
Page 7 and 8: The Essentials of Patient Safety he
Page 9 and 10: The Essentials of Patient Safety Re
Page 11 and 12: The Essentials of Patient Safety v
Page 13 and 14: The Essentials of Patient Safety Ma
Page 15: The Essentials of Patient Safety an
Page 19 and 20: The Essentials of Patient Safety le
Page 21 and 22: The Essentials of Patient Safety Bo
Page 23 and 24: The Essentials of Patient Safety tw
Page 25 and 26: The Essentials of Patient Safety s
Page 27 and 28: The Essentials of Patient Safety 6.
Page 29 and 30: The Essentials of Patient Safety a
Page 31 and 32: The Essentials of Patient Safety Ta
Page 33 and 34: The Essentials of Patient Safety dr
Page 35 and 36: The Essentials of Patient Safety 7.
Page 37 and 38: The Essentials of Patient Safety Pa
Page 39 and 40: The Essentials of Patient Safety Ta
Page 41 and 42: The Essentials of Patient Safety Te
Page 43 and 44: The Essentials of Patient Safety Br
Page 45 and 46: The Essentials of Patient Safety KE
Page 47 and 48: The Essentials of Patient Safety CH
Page 49 and 50: The Essentials of Patient Safety ce
Page 51 and 52: The Essentials of Patient Safety Su
Page 53: The Essentials of Patient Safety KE

The Essentials of Patient Safety - Clinical Human Factors Group

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?