learning from medical errors clinical problems

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Learning From Medical Errors

Author : Anh Vu Nguyen
ISBN : 9781498799867
Genre : Medical
File Size : 65. 96 MB
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The upheavals of the NHS reforms have caused a great deal of stress and uncertainty in primary care, and professional development and support for general practitioners needs to take account of this. This book offers a group supervision model which can be used to develop the core competencies needed for GPs to make the new primary care organisations work. The book analyses how primary care professionals have dealt with the various reforms of the past decade, and picks apart the paralysing culture of politeness, conflict avoidance and rivalry for power, to reveal how at the core of reform is the struggle for each GP to construct a new professional identity which integrates medicine, management and politics.It proposes ways GPs can benefit from these experiences to become equipped with the necessary competencies to be active members or dynamic leaders in the new primary care organisations. The doctor-patient relationship is no longer one-to-one, but located within a group matrix, in the same way that a GP is now required to work within a group framework. This book enables GPs to develop the essential group skills they now need, and on which the success of the healthcare reforms ultimately depends. 'A challenging approach to understanding and supporting the individuals who make up the primary care workforce. Gerhard Wilke has drawn on his experiences to identify the reasons behind the 'dis-ease' felt by many practitioners, and to suggest models for improving their morale. This book will be of interest to practitioners working through the challenges of continuing 'top down' reorganisation of the NHS and responding to the reconfiguration of general practice partnerships into PCGs and PCTs.'

Complications

Author : Atul Gawande
ISBN : 9781847651242
Genre : Biography & Autobiography
File Size : 77. 27 MB
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The international bestseller from the author of Being Mortal In these gripping accounts of true cases, bestselling author Atul Gawande performs exploratory surgery on medicine itself, laying bare a science not in its idealised form, but as it actually is - complicated, perplexing and profoundly human. This is a stunningly well-written account of the life of a surgeon: what it is like to cut into people's bodies and the terrifying - literally life and death - decisions that have to be made: operations that go wrong; of doctors who go to the bad; why autopsies are necessary; what it feels like to insert your knife into someone. 'Written as tautly as a thriller' Observer

The Learning Healthcare System

Author : Institute of Medicine
ISBN : 0309133939
Genre : Medical
File Size : 57. 35 MB
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As our nation enters a new era of medical science that offers the real prospect of personalized health care, we will be confronted by an increasingly complex array of health care options and decisions. The Learning Healthcare System considers how health care is structured to develop and to apply evidence--from health profession training and infrastructure development to advances in research methodology, patient engagement, payment schemes, and measurement--and highlights opportunities for the creation of a sustainable learning health care system that gets the right care to people when they need it and then captures the results for improvement. This book will be of primary interest to hospital and insurance industry administrators, health care providers, those who train and educate health workers, researchers, and policymakers. The Learning Healthcare System is the first in a series that will focus on issues important to improving the development and application of evidence in health care decision making. The Roundtable on Evidence-Based Medicine serves as a neutral venue for cooperative work among key stakeholders on several dimensions: to help transform the availability and use of the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and, ultimately, to ensure innovation, quality, safety, and value in health care.

Resident Duty Hours

Author : Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety
ISBN : 9780309127769
Genre : Medical
File Size : 68. 84 MB
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Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue. Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning. All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Medication Errors

Author : Robert Naylor
ISBN : 1857759567
Genre : Medical
File Size : 22. 62 MB
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An examination of the incidence and causes of adverse events. Using data obtained from hospitals from the United Kingdom, United States and other developed countries, it examines the risk factors leading to errors, the human and financial costs, and the scope to reduce errors.

Beyond The Checklist

Author : Suzanne Gordon
ISBN : 9780801465789
Genre : Medical
File Size : 21. 44 MB
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The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.

Human Error In Medicine

Author : Marilyn Sue Bogner
ISBN : 9781351440202
Genre : Technology & Engineering
File Size : 66. 35 MB
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This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.

How Doctors Think

Author : Jerome Groopman
ISBN : 0547348630
Genre : Medical
File Size : 71. 4 MB
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On average, a physician will interrupt a patient describing her symptoms within eighteen seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. Often, decisions made this way are correct, but at crucial moments they can also be wrong -- with catastrophic consequences. In this myth-shattering book, Jerome Groopman pinpoints the forces and thought processes behind the decisions doctors make. Groopman explores why doctors err and shows when and how they can -- with our help -- avoid snap judgments, embrace uncertainty, communicate effectively, and deploy other skills that can profoundly impact our health. This book is the first to describe in detail the warning signs of erroneous medical thinking and reveal how new technologies may actually hinder accurate diagnoses. How Doctors Think offers direct, intelligent questions patients can ask their doctors to help them get back on track. Groopman draws on a wealth of research, extensive interviews with some of the country’s best doctors, and his own experiences as a doctor and as a patient. He has learned many of the lessons in this book the hard way, from his own mistakes and from errors his doctors made in treating his own debilitating medical problems. How Doctors Think reveals a profound new view of twenty-first-century medical practice, giving doctors and patients the vital information they need to make better judgments together.

Patient Safety Workshop

Author : World Health Organization
ISBN : 9241599022
Genre : Medical
File Size : 58. 63 MB
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This booklet which includes a CD-ROM should enable any health-care worker to facilitate a workshop on patient safety. This workshop explores how multiple weaknesses present within the hospital system can lead to error. It aims to provide all health-care workers and managers with an insight into the underlying cause of such events. Although the workshop materials revolve around an error involving the inappropriate administration of vincristine, the underlying principles of why an error occurs are universal and the learning objectives can be applied in any error-related situation.

To Err Is Human

Author : Institute of Medicine
ISBN : 9780309261746
Genre : Medical
File Size : 47. 72 MB
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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