Medical Error and Patient Safety Human Factors in Medicine 1st Edition by George Peters, Barbara Peters 9781040173367 1040173365

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ISBN 10: 1040173365
ISBN 13: 9781040173367
Author: George Peters, Barbara Peters

A difficult and recalcitrant phenomenon, medical error causes pervasive and expensive problems in terms of patient injury, ineffective treatment, and rising healthcare costs. Simple heightened awareness can help, but it requires organized, effective remedies and countermeasures that are reasonable, acceptable, and adaptable to see a truly significant drop in the intolerable rate of medical mistakes. Only with better understanding, knowledge, and directed techniques can there be rapid and marked improvement in medical error management discipline. Since medical error is situation specific and involves diverse variables in equipment, environment, and human performance, the correct choice of preventive and corrective techniques is critical. Providing a wealth of useful ideas, concepts, and techniques, Medical Error and Patient Safety: Human Factors in Medicineuses abroad perspective to present more than 500 remedies that can be applied and tailored to your unique circumstances. This detailed review of so many measures enables you to correctly identify needs and undertake appropriate actions to achieve a success that can be measured in avoided injuries, improved healthcare, and reduced cost. Thought provoking and useful, this book considers the potential for error and the possibility for improvement in every aspect of healthcare. After an introduction to general concepts and approaches, it examines vulnerabilities in medical services, including emergency services, healthcare facilities, and infection control. It covers risks in medical devices and product design; human factors such as fatigue and stress; management errors; errors in communication at all levels of the healthcare hierarchy; as well as mistakes in drug delivery including faulty labels and warnings. The authors also compare and contrast several analytical methods, their interpretation, and their translation into a plan of action.

Medical Error and Patient Safety Human Factors in Medicine 1st Table of contents:

Chapter 1: Introduction

• Common Understanding

• Sophisticated Knowledge

• Current Urgency

• Medication Errors

• Pediatric Dosing Errors

• Prescription Drug Listing

• Toxic Exposures

• Laboratory Errors

• Patient Identification Errors

• Adverse Event Reports

• Adverse Event Rates Worldwide

• Wrong-Site Surgery

• Infection Control

• Time to Rebuild

• Our Approach

• A New Meaning for Error

• Multidisciplinary Orientation

Chapter 2: General Concepts

• Causation

• General Causation

• The Rule-Out Process

• Relative Risk

• The But-For Technique

• Correlative Relationships

• Substantial Factor Test

• Concurring Cause

• Intervening Causation

• Remote Causation

• Proximate Cause

• Meta-Analysis

• Risk Factors

• Warning Causation

• Mixed Causation

• Bias

• Intrinsic Bias

• Extrinsic Bias

• Intentional Bias

• Knee

• Head

• Performance Criteria

• Physicians

• Nurses

• Hospitals

• Nonmedical Professionals

• The Pursuit of Excellence

• Financial Viability

• Medical Devices and Equipment

• Transparency

• Harmonization

• Teamwork

• Rationalization

• Assurance Techniques

• Management of Error

• Caveats

Chapter 3: Medical Services

• Theoretical Assumptions

• Equal Status

• Civility

• Innocent Errors

• Patient Involvement

• Honesty

• Ombudsman

• Conflicts of Interest

• System Dynamics

• Medication Errors

• Extent of the Problem

• Prevention Strategies

• Individual Remedies

• Computerized Systems

• Radio-Frequency Identification Device Technology

• Clinical Conversations

• Comparative Risks

• Infection Control

• Sources of Contamination

• Use of Antibiotics

• Medical Waste

• Staff Immunization

• Nosocomial Pneumonia

• Call Lights

• Drug Resistance

• Touch Surfaces

• Lessons Learned

• Emergency Services

• Handovers and Interactions

• Health Care Facilities

• Cost Benefits

• Clean Air

• Clustering and Flexibility

• Patient Variability

• General Criteria

• Limitations of Service

• Caveats

• Proof

• Specificity

• Culture

• Architecture

• Handoffs

• Emergency Services

• Call Lights

• Basic Hygiene

• Mutations

• Decision Making

• Surgical Infection Control

• Choice Behavior

• Rules of the Road

• The User Process

Chapter 4: Medical Devices

• Risks

• Inherent

• Illustrative Problems

• Human Error

• Neurostimulation

• Corrective Remedies

• Product Life

• Biofilms

• Reprocessing

• Subcontracting

• Portability

• Toxic Materials

• Testing

• Error Reduction

• Learning Process

• Time Delays

• Formal Requirements

• Analytical Techniques

• Automation

• External Requirements

• Standards

• Outsourcing

• Disciplinary Emphasis

• Communications

• Effectiveness

• Complications

• Ambiguity

• Content

• Product Design

• Essentials

• World Trade Problems

• Customer Satisfaction

• Critical Comments

• Conclusions

• Caveats

Chapter 5: Analysis

• Corrective Action

• Preventive Action

• System Analysis

• Human Error Control

• Risk Assessment

• Mistaken Beliefs

• Observational Demeanor

• Correct Terminology

• Complete Process

• Post-Control Measures

• Operational Discipline

• Error Troubleshooting

• Traceability

• Industrial Engineering

• Quality Assurance

• Introduction

• Drug Delivery

• Change Management

• Bed Assignment

• Medication Administration

• Pharmacy Errors

• Quality Techniques

• Quality Standards

• Limitations

• Quality Programs

• Caution

• Other Disciplines

• Government and Industry Reviews

• In-House Teams

• Personality Factors

• Individual Responsibility

• Minimalists

• Discretionary Agents

• Caveats

• Choice

• Reaction

• Persistence

• Self-Help

• Economic Evaluations

• Risk Assessments

• Fuzziness

• Application

• Time Frames

Chapter 6: Human Factors

• Hospital Beds

• Fatigue

• Characteristics

• Causes

• Prevention

• On-Call Problems

• Work Shifts

• Defiant Actions

• Stress

• Situation Awareness

• Reduction and Integration

• Patient Handling

• Drug-Altered Behavior

• Macroergonomics

• Team Training

• Human Factors Experts

• Cultural Change

• Sentinel Events

• Tubing and Catheter Connections

• Electrical Mismatches

• Plugs and Disposable Interconnects

• Surgical Fires

• Ventilator Problems

• Scope of Activities

• Caveats

• Stress

• Fatigue

• Situation Awareness

• Defiant Actions

• Self-Limitations

• Human Engineering

• Cognitive Illusions

• Brand Bias

• Packaging

• Electronics

Chapter 7: Management Errors

• Introduction

• Illustrative Error Sources

• Managerial

• Organizational

• Transformational Issues

• Transitional Clinics

• Nursing Home Changes

• Assisted-Living Facilities

• Home Use Devices

• Reliability of Implantable Devices

• Disclosures

• Pandemics

• Management Principles

• Introduction

• Shared Goals

• Placebo Effects

• Layering

• Management Concerns

• Conformance

• Competition

• Electronic Records and Telemedicine

• Health Middlemen

• Caveats

• Risk Control

• Management Action

• Remote Control

• Error Detectives

• Liability Reasoning

• Management Oversight

• Personal Attitudes

• Feedback

• Conflict

• Unpaid Claims

Chapter 8: Communications

• Interactivity

• Acknowledged Problems

• Physician-Patient Communications

• Multiple Communication Errors

• System Errors

• Laboratory Mistakes

• Consumer Beliefs

• The Culture of Silence

• Supplemental Techniques

• Cascade Analysis

• Cluster Analysis

• Network Analysis

• Critical Path Analysis

• Important Variables

• Technical Information

• Psychological Costs

• Intellectual Factors

• Emotional Factors

• Nurse-Patient Communications

• Cognitive Dissonance

• Records Control

• Signal Detection and Perceptual Set

• Communicating Consent

• Informed Consent

• Unconsciousness

• Comatose Patients

• Misreading Symptoms

• Caveats

• Garbling

• Effectiveness

• Cognition

• Informed Consent

• Misreading

• Beliefs

• Silence

• Caution

• Nurse Communications

• Fraud, Waste, and Abuse

• Time Lags

Chapter 9: Drug Delivery

• Containers

• Labels

• Warnings

• Basic Objectives

• Residual Risk

• Compliance

• Graphics and Symbols

• Sign Offs

• Adequacy

• Reinforcement

• Mental Processes

• Potentiation

• Subthreshold Reactions

• Language Control

• Intrinsic Brain Activity

• Derivative Criteria

• Pill Matching

• Instructions

• Regulation

• Special Conditions of Use

• Antibiotic Approvals

• Expert Panels

• Over-the-Counter Drugs

• FDA Limitations

• Public Policy Concerns

• Prescription Directions

• Security and Counterfeiting

• Recalls

• Possible Problems

• Complexity

• Scale-Up

• Waste

• Verification

• Collaboration

• Networking and Privacy Protection

• Online Searches

• Privacy Rules

• Waiver of Privacy

• Responses

• Patient Concerns

• Caveats

• Messages

• Symbols and Graphics

• Warnings

• Over-the-Counter Drugs

• Labels

• Packaging

• Outserts

• Internet Prescriptions

• Patients

• Disclosure of Errors

• Standards

• Robustness

• Health Care Costs

• Adverse Events

• Noncompliance

• References and Recommended Reading

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Tags: Medical Error, Patient Safety, George Peters, Barbara Peters