Additional Information
Book Details
Abstract
Guest Editor Juan Sanchez reviews articles in Safe Surgery for the general surgeon. Articles include iatrogenesis: the nature, frequency, and science of medical errors, risk management and the regulatory framework for safer surgery medication, lab, and blood banking errors, surgeons' non-technical skills, creating safe and effective surgical teams, human factors and operating room safety, systemic analysis of adverse events: identifying root causes and latent errors, information technologies and patient safety, patient safety and the surgical workforce, measuring and preventing healthcare associated infections, the surgeon's four-phase reaction to error, universal protocols and wrong-site/wrong-patient events, unconscious biases and patient safety, and much more!
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Patient Safety | i | ||
| Copyright Page | ii | ||
| Table of Contents | vii | ||
| Contributors | iii | ||
| Foreword: Patient Safety | xiii | ||
| Preface: Patient Safety | xvii | ||
| Chapter 1. High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care | 1 | ||
| THE HIGH RELIABILITY ORGANIZATION | 1 | ||
| TEAMWORK AND HIGH RELIABILITY ORGANIZATIONS | 6 | ||
| CLINICAL MICROSYSTEMS | 7 | ||
| SUMMARY | 11 | ||
| REFERENCES | 12 | ||
| Chapter 2. Building High-Performance Teams in the Operating Room | 15 | ||
| LEARNING FROM THOSE THAT DO IT WELL | 15 | ||
| DEVELOPING THE TEAM—DOES EVERYONE KNOW THE GOAL? | 16 | ||
| OK, WHAT ARE SOME PRACTICAL INTERVENTIONS? | 17 | ||
| THERE IS NO EASY FIX AND THE RETURN ON INVESTMENT IS TOUGH TO QUANTIFY | 18 | ||
| REFERENCES | 19 | ||
| Chapter 3. Human Factors and Operating Room Safety | 21 | ||
| THE OR ENVIRONMENT | 22 | ||
| TEAMWORK AND COMMUNICATION | 24 | ||
| TOOLS AND TECHNOLOGY | 27 | ||
| TASK AND WORKLOAD FACTORS | 29 | ||
| ORGANIZATIONAL INFLUENCES | 30 | ||
| SUMMARY | 33 | ||
| REFERENCES | 33 | ||
| Chapter 4. Surgeons’ Non-technical Skills | 37 | ||
| BEHAVIORAL MARKER SYSTEMS | 38 | ||
| THE NOTSS PROJECT | 39 | ||
| BREAKING DOWN NOTSS | 40 | ||
| SUMMARY | 47 | ||
| REFERENCES | 48 | ||
| Chapter 5. A Comprehensive Unit-Based Safety Program (CUSP) in Surgery: Improving Quality Through Transparency | 51 | ||
| THE SCIENCE FOR COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP) IN SURGERY | 51 | ||
| NEVER EVENTS | 52 | ||
| WRONG-SITE/WRONG-PATIENT SURGERY | 52 | ||
| PROTOCOLS AND CULTURE CHANGES TO PREVENT ERROR | 54 | ||
| MEASURING QUALITY IN SURGERY | 57 | ||
| SUMMARY | 61 | ||
| REFERENCES | 61 | ||
| Chapter 6. Hospital-Acquired Infections | 65 | ||
| CRBSI | 66 | ||
| VAP | 68 | ||
| SSI | 70 | ||
| CAUTI | 71 | ||
| SUMMARY | 73 | ||
| REFERENCES | 73 | ||
| Chapter 7. Information Technologies and Patient Safety | 79 | ||
| IMPLEMENTATION OF EHRS FOR SURGICAL CARE | 80 | ||
| BAR CODE TECHNOLOGY AND RFID | 82 | ||
| INTRAOPERATIVE MONITORING AND PATIENT SAFETY | 83 | ||
| AUTOMATED DATA COLLECTION | 84 | ||
| SUMMARY | 84 | ||
| ACKNOWLEDGMENTS | 85 | ||
| REFERENCES | 85 | ||
| Chapter 8. Adverse Events:Root Causes andLatent Factors | 89 | ||
| A DIFFERENT APPROACH | 90 | ||
| LATENT FACTORS AND ROOT CAUSES | 90 | ||
| THEORIES OF ERROR | 91 | ||
| RCA METHODS | 92 | ||
| MULTIPLE CAUSES ANALYSIS | 95 | ||
| THE CONSEQUENCES OF THE PERSON APPROACH TO MEDICAL ERROR | 97 | ||
| SECRECY, MALPRACTICE, AND ERROR | 97 | ||
| DO RCAs WORK? | 97 | ||
| SCENARIO 1: ULTIMATE RESOLUTION | 98 | ||
| WHEN TO PERFORM CAUSE ANALYSIS | 99 | ||
| REFERENCES | 99 | ||
| Chapter 9. Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events | 101 | ||
| WHAT HAS BEEN LEARNED FROM ROOT CAUSE ANALYSIS ABOUT SURGERY-RELATED ADVERSE EVENTS? | 101 | ||
| WHAT HAS BEEN LEARNED FROM RCA? | 104 | ||
| MEASURING SAFETY: THE ACCIDENT PARADOX | 105 | ||
| HAVE RCAs ALTERED THE IMPROVEMENT CAPABILITY OF SURGICAL CENTERS? | 105 | ||
| RESPONDING TO THE LIMITATIONS OF RCA | 109 | ||
| HAS THE EXCLUSIVE FOCUS ON RCA LED HEALTH CARE ASTRAY? | 112 | ||
| CONCLUDING THOUGHTS | 112 | ||
| REFERENCES | 113 | ||
| Chapter 10. Residency Training Oversight(s) in Surgery: The History and Legacy of the Accreditation Council for Graduate Medical Education Reforms | 117 | ||
| LIBBY ZION AND THE EVALUATION OF ACGME OVERSIGHT OF RESIDENCY TRAINING | 118 | ||
| TEETH IN THE ACGME REGULATIONS: THE CURRENT SYSTEM | 118 | ||
| ALTERNATIVES TO THE CURRENT SYSTEM | 118 | ||
| EDUCATIONAL RESEARCH: 2 WAVES OF ACGME REGULATIONS | 119 | ||
| UNANSWERED QUESTIONS AND UNINTENDED CONSEQUENCES | 119 | ||
| SAFETY CULTURE AND HANDOFFS | 120 | ||
| WORK HOURS AND EDUCATION | 120 | ||
| SUMMARY | 122 | ||
| REFERENCES | 122 | ||
| Chapter 11. Teaching the Slowing-down Moments of Operative Judgment | 125 | ||
| THEORETIC FRAMEWORK | 126 | ||
| EXPERTISE IN SURGERY: SLOWING DOWN WHEN YOU SHOULD | 128 | ||
| SLOWING DOWN AND THE SURGEON EDUCATOR | 131 | ||
| TEACHING IMPLICATIONS | 132 | ||
| SUMMARY | 134 | ||
| REFERENCES | 134 | ||
| Chapter 12. The Role of Unconscious Bias in Surgical Safety and Outcomes | 137 | ||
| WHAT IS UNCONSCIOUS BIAS IN MEDICINE? | 138 | ||
| EVIDENCE OF UNCONSCIOUS BIAS IN NATURALISTIC STUDIES | 139 | ||
| EVIDENCE OF UNCONSCIOUS BIAS IN EXPERIMENTAL STUDIES | 140 | ||
| THE EFFECT OF UNCONSCIOUS BIAS ON THE PHYSICIAN-PATIENT ENCOUNTER | 142 | ||
| REDUCING UNCONSCIOUS BIAS AND IMPROVING SURGICAL SAFETY | 142 | ||
| SUMMARY | 144 | ||
| REFERENCES | 144 | ||
| Chapter 13. When Bad Things Happen to Good Surgeons: Reactions to Adverse Events | 153 | ||
| VIGNETTE | 153 | ||
| FRAMEWORK FOR UNDERSTANDING INDIVIDUAL SURGEONS’ REACTION TO ADVERSE EVENTS | 155 | ||
| 4 PHASES OF REACTION TO ADVERSE EVENTS | 155 | ||
| IMPLICATIONS: PLACING THE FRAMEWORK INTO CONTEXT | 156 | ||
| FUTURE DIRECTIONS AND SUMMARY | 159 | ||
| REFERENCES | 159 | ||
| Chapter 14. Open Disclosure of Adverse Events: Transparency and Safety in Health Care | 163 | ||
| WHY DISCLOSE ADVERSE EVENTS? | 164 | ||
| THE ETHICAL OBLIGATION FOR DISCLOSURE | 164 | ||
| PROFESSIONAL DUTY | 165 | ||
| LEGAL AND REGULATORY MANDATE | 166 | ||
| DISCLOSURE LINK TO PATIENT SAFETY | 166 | ||
| DISCLOSURE LINKED TO SYSTEMS IMPROVEMENTS | 167 | ||
| DISCLOSURE: THE INTEGRATED TEAM APPROACH | 167 | ||
| CLINICAL DISCLOSURE | 170 | ||
| INSTITUTIONAL DISCLOSURE | 170 | ||
| BARRIERS TO DISCLOSURE | 172 | ||
| THE COOPERATION CLAUSE OF EMPLOYMENT AND INSURANCE CONTRACTS | 173 | ||
| REMOVING BARRIERS | 173 | ||
| SUMMARY | 175 | ||
| REFERENCES | 176 | ||
| Index | 179 |