Download Clinical risk management : enhancing patient safety by John Williams, Charles Vincent PDF

By John Williams, Charles Vincent

The purpose of this ebook is to minimize the dangers of scientific remedy and increase the protection of sufferers in all components of healthcare. the 1st part discusses human blunders, the prevalence of damage to sufferers, and the improvement or chance administration. Chapters within the moment part speak about the aid of probability in medical perform in key scientific specialties. The 3rd part discusses gains of the healthcare platforms which are necessary to secure perform, similar to conversation of hazard to sufferers, the layout of kit, supervision and coaching, and potent teamwork. The fourth part describes the best way to placed probability administration into perform, together with the potent and delicate dealing with of lawsuits and claims, the care of injured sufferers and the workers concerned, and the reporting, research and research of significant incidents.

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Permanent disability resulted from 8·4% of adverse events and death from 6·6%. Operative adverse events comprised 44·9% of all adverse events followed by adverse drug events (19·3%). Most adverse events occurred in operating rooms. Negligent adverse events were common in emergency rooms (and 94% of events attributed to emergency medicine physicians were judged negligent), intensive care units and patient rooms on general wards. The investigators also estimated the total costs of adverse events (including direct healthcare costs and indirect costs such as lost household production and time off work).

Attentional “capture” (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet its occurrence is almost impossible to predict or control effectively. The same is true of the factors 28 UNDERSTANDING ADVERSE EVENTS 7 8 9 10 11 associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. People do not act in isolation. Their behaviour is shaped by circumstances.

1988 ILEEE Fourth Conference on Human Factors and Power Plants. New York: Institute for Electrical and Electronic Engineers, 1988: 200–31. 16 Reason J, Mycielska K. Absent-minded? The psychology of mental lapses and everyday errors. Englewood Cliffs, NJ: Prentice-Hall, 1982. 17 Reason J. Managing the risks of organisational accidents. Aldershot: Ashgate, 1997. 18 Hudson P, Reason J, Wagenaar W, et al. Tripod Delta: proactive approach to enhanced safety. J Petroleum Technology 1994;46:58–62. 19 Weick KE.

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