To do no harm: ensuring patient safety in health care organizations

Foreword ix Lucian L. Leape Preface xv Acknowledgments xxiii The Authors xxvii Introduction 1 1 Declare Patient Safety Urgent and a Priority 12 2 Error and Harm in Health Care 23 3 Understanding the Basics of Patient Safety 44 4 Assume Executive Responsibility 71 5 Import New Knowledge and Skills 96 6 Install a Blameless Reporting System 120 7 Assign Accountability 148 8 Align External Controls and Reform Education 181 9 Accelerate Change For Improvement 204 10 The End of the Beginning 234 References 245 Glossary 255 Appendixes 1 Checklist for Assessing Institutional Resilience 279 2 Creating De-Identified Case Studies for Dissemination 283 3 Medical Accidents Policy: Reporting and Disclosure, Including Sentinel Events 285 4 Medication Safety Team Feedback Form 295 5 Patient Safety Workplan 297 6 Safety Learning Report 300 7 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 303 8 Complexity Lens Reflection 308 9 A Brief Look at Gaps in the Continuity of Care 311 10 A Brief Look at the New Look in Complex System Failure, Error, and Safety 313 11 A Reminder on Every Chart 315 12 List of Serious Reportable Events in Health Care 316 13 Statement of Principle: Talking to Patients About Health Care Injury 321 14 VHA Patient Safety Organizational Assessment 322 Additional Readings 331 Resources 335 Index 345.

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With this important resource, health care leaders from the board room to the point-of-care can learn how to apply the science of safe and best practices from industry to healthcare by changing leadership practices, models of service delivery, and methods of communication.