Kalra Medical Errors and Patient Safety

Strategies to reduce and disclose medical errors and improve patient safety
1. Auflage 2011
ISBN: 978-3-11-024950-7
Verlag: De Gruyter
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, Band 1, 121 Seiten, Format (B × H): 170 mm x 240 mm

Reihe: Patient Safety

Is the reporting of medical errors changing? This book shows with real cases from health care and beyond that most errors come from flaws in the system. It also shows why they don't get reported and how medical error disclosure around the world is shifting away from blaming people, to a "no-fault" model that seeks to improve the whole system of care.

The book intends to provide an introduction to medical errors that result in preventable adverse events. It will examine issues that stymie efforts made to reduce preventable adverse events and medical errors, and will moreover highlight their impact on clinical laboratories and other areas, including educational, bioethical, and regulatory issues. Varying error rates of 0.1-9.3% in clinical diagnostic laboratories have been reported in the literature. While it is suggested that fewer errors occur in the laboratory than in other hospital settings, the quantum of laboratory tests used in healthcare entails that even a small error rate may reflect a large number of errors. The interdependence of surgical specialties, emergency rooms, and intensive care units - all of which are prone to higher rates of medical errors - with clinical diagnostic laboratories entails that reducing error rates in laboratories is essential to ensuring patient safety in other critical areas of healthcare.

The author maintains that many such errors are preventable provided that appropriate attention is paid to systemic factors involved in laboratory errors. This book identifies possible intelligent system approaches that can be adopted to help control and eliminate these errors. It is a valuable tool for physicians, clinical biochemists, research scientists, laboratory technologists and anyone interested in reducing adverse events at all levels of healthcare processes.

Zielgruppe

Physicians, Clinical Biochemists, Research Scientists, Laboratory

Autoren/Hrsg.

Kalra, Jay

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Vorklinische Medizin: Grundlagenfächer Biochemie (med.)
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Labormedizin
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Biomedizin, Medizinische Forschung, Klinische Studien

Inhaltsverzeichnis

1;Contents;8
2;Acknowledgments;10
3;About the author;12
4;Abbreviations;14
5;1 An overview and introduction to concepts;16
5.1;1.1 Introduction;16
5.2;1.2 Medical error;17
5.3;1.3 Magnitude and epidemiology of health care errors;19
5.4;1.4 Conclusion;23
6;2 Perceptions of medical error and adverse events;26
6.1;2.1 Introduction;26
6.2;2.2 Perceptions by physicians;27
6.3;2.3 Perceptions by the public;28
6.4;2.4 Perceptions by health care staff;30
6.5;2.5 Perceptions by medical students;32
6.6;2.6 A sociological perception of medical error;34
6.7;2.7 Conclusion;35
7;3 Causes of medical error and adverse events;38
7.1;3.1 Introduction;38
7.2;3.2 The cognitive influence on error-generating behavior;42
7.3;3.3 Conclusion;43
8;4 Medical error and strategies for working solutions in clinical diagnostic laboratories and other health care areas;46
8.1;4.1 Introduction;46
8.2;4.2 Clinical diagnostic laboratories;47
8.3;4.3 Errors in different stages of analysis;49
8.4;4.4 Strategies for identification and prevention of errors;51
8.5;4.5 Errors in emergency medicine;53
8.6;4.6 Errors in intensive care medicine;56
8.7;4.7 Conclusion;60
9;5 Creating a culture for medical error reduction;66
9.1;5.1 Introduction;66
9.2;5.2 Education and professional development;67
9.3;5.3 Error reporting systems;72
9.4;5.4 Leadership and regulatory issues;74
9.5;5.5 Establishing a quality care council;75
9.6;5.6 Emotional impact of errors on health care professionals;76
9.7;5.7 Conclusion;76
10;6 Improving quality in clinical diagnostic laboratories;80
10.1;6.1 Introduction;80
10.2;6.2 Efforts and programs to ensure quality in clinical diagnostic laboratories;81
10.3;6.3 Proficiency testing in clinical laboratories;84
10.4;6.4 External quality assessment and proficiency testing programs;85
10.5;6.5 "No-fault" model;87
10.6;6.6 Conclusion;88
11;7 Barriers to open disclosure;92
11.1;7.1 Introduction;92
11.2;7.2 How to disclose;92
11.3;7.3 Disclosing errors to multiple patients;93
11.4;7.4 Bioethical viewpoints;94
11.5;7.5 Patient-physician relations;95
11.6;7.6 The dilemma of an apology;96
11.7;7.7 Barriers to full disclosure;98
11.8;7.8 Conclusion;99
12;8 International laws and guidelines addressing error and disclosure;102
12.1;8.1 Introduction;102
12.2;8.2 Disclosing preventable adverse events;102
12.3;8.3 International progress and initiatives;103
12.4;8.4 Conclusion;107
13;9 The value of autopsy in detecting medical error and improving quality;110
13.1;9.1 Introduction;110
13.2;9.2 Error in diagnostic medicine;110
13.3;9.3 Missed diagnosis and discordance;111
13.4;9.4 The value of autopsies;112
13.5;9.5 Autopsy decline and strategies to encourage autopsy;113
13.6;9.6 Conclusion;114
14;10 Total quality management, six-sigma, and health care;118
14.1;10.1 Introduction;118
14.2;10.2 New issues, newer solutions;119
14.3;10.3 The six-sigma structure;121
14.4;10.4 Six-sigma in clinical diagnostic laboratories;123
14.5;10.5 Conclusion;124
15;Index;126

Über Autor(innen)

Jay Kalra, College of Medicine, University of Saskatchewan, Canada.