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From page 273... ... , 7-8, 69-71, 75-84, 135 Centers for Education and Research in Therapeutics, 77-78, 83 Consumer Assessment of Health Plans, 20 Aircraft carriers, 57, 160-161 Air transport, see Aviation Alaska, 142 Alcoa, Inc., 160 Allergic reactions, drugs, 33, 192 273 Read the entire page →
From page 274... ... , 72-73,76,91,95-97,104,105106,125,127 B Bar coding, 175,188,189,195-196 Benchmarking, 81,182,259 Best practices, 18,32,77,79,145,152, 182,193 see also Clinical practice guidelines Billings, Charles, 73 Budgetary issues, see Funding Bureau of Labor Statistics, 73-74,97 California peer review statute, 127-128 reporting system, 254-255 Cancer, 1, 26,209 Read the entire page →
From page 275... ... patient data, general, 178 Privacy Act, 123 voluntary, 94, 95, 109-131, 256 Connecticut, 91, 256 Consumer Assessment of Health Plans, 20 Cost and cost-benefit factors, 29, 40-42, 158, 248-253 ambulatory care settings, errors, 41 Center for Patient Safety (proposed) , 76 drugs and drug errors, 2, 27, 30, 32, 41, 182-183, 191, 194-195, 248-253 national, 1-3, 27, 40-42 National Medical Expenditure Survey, 38, 234-235 uninsured persons, 24 see also Funding Court cases, see Litigation Critical incident analysis, see Human factors Cultural factors, 4, 146 access to care, 24 organizational, culture of safety, 12-13, 14, 155-156, 159-162, 166-168, 178, 179, 189 public opinion, 2, 29, 42-43, 70, 167 see also Attitudes Read the entire page →
From page 276... ... Centers for Disease Control and Prevention, 99, 268 INDEX Health Care Financing Administration, 19-20, 82,139, 140-141 reporting systems,121-123 see also Agency for Health Care Research and Quality; Food and Drug Administration Department of Labor, see Bureau of Labor Statistics Department of Transportation, see Federal Aviation Administration; National Transportation Safety Board Department of Veterans Affairs National Patient Safety Partnership, 78, 81-82, 183, 191, 196 Veterans Health Administration, 80, 83, 123 Devices and equipment, 82, 184-185, 190191, 260 affordances, 163, 171-172 default mode, 62, 171, 176 forcing functions, 158, 164, 170, 171 home care, 63 human-machine interface, 62-63, 175 infusion pumps, 50-66 (passim) , 150, 171, 172, 183, 255, 257 natural mapping, 163-164, 171 outpatient care, 165 standards and standardization, 23, 62, 144, 148-151, 156, 164, 172173, 197 see also Food and Drug Administration Diagnostic errors, 36, 79 Diphenhydramine hydrochloride, 34 Disabilities, 1-2, 30, 220-221, 261 Drugs, 1, 221 allergic reactions, 33, 192 antibiotics, 33, 171 anticoagulants, 35 antidiarrheals, 34 anti-inflammatory drugs, 35, 253-254 Centers for Education and Research in Therapeutics, 77-78, 79 chemotherapy, 1, 51, 164, 171, 194, 260 Read the entire page →
From page 277... ... program, 95, 97, 100, 125, 126127, 194 MedMARx, 95,100, 126 MedWatch, 99, 123, 148-149 mortality, 28, 32-33, 42, 227, 229, 233, 248-249 naloxone hydrochloride, 34 names of, 29, 37, 136, 148, 149, 151, 184,231 National Patient Safety Partnership, 82 nursing homes, 42 order entry systems, 33, 40, 62, 80, 172, 175, 183, 184, 185, 188 189, 190, 191-192 organizational factors, 13, 14, 157-158, 168, 171, 172, 174, 175, 177, 182-197 packaging and labeling, 13, 64, 136, 148, 151, 185, 187, 193 bar coding, 175, 188, 189, 195-196 277 patient compliance, 35, 37, 39, 174, 236-237 pharmacies, 2, 27, 32, 51, 183, 186187, 192-193 pharmacists, 2, 13, 27, 34, 39, 145, 183, 186-187, 193, 194-195, 224-225, 230-233, 236-237, 240245 potassium chloride, 171, 187, 194 prescription writing, 33, 37-39, 54, 183, 184, 190, 231, 241 protocols, 6, 77, 92, 141, 158, 164, 171, 173, 177, 183, 186, 187, 193-194 chemotherapy, 164,171, 194 reporting systems, 34, 93, 95, 98-99, 100 FDA, 93, 95, 98-99, 100, 104, 105, 123, 148-149 selected states, descriptions, 255, 257, 261 standards and standardization, 13, 14, 23, 29, 171, 183, 184-185, 190191 surgery, 34, 40, 228-229; see also Anesthesia unit dosing, 183, 184-185, 193 see also Food and Drug Administration Economic factors ambulatory care, 165 incentives, 18, 19-20, 21 market-based initiatives, 6, 17, 19-20, 21 uninsured persons, 24 worker productivity losses, 2-3 see also Cost and cost-benefit factors; Employment factors; Funding: Insurance; Purchasers Education, see Patient education; Professional education; Public education E.I. du Pont de Nemours and Company, 159-160 Read the entire page →
From page 278... ... , 72-73 Center for Patient Safety (proposed) , 7-8, 70, 76, 78-79, 83-84, 106 NIH, 82 NIOSH, 83 organizational safety environment, 166, 168 reporting systems, 9, 10, 72-73, 88, 89, 106 study at hand, x H Harvard Medical Practice Study, 5, 30 Health Care Financing Administration, 19-20, 82, 139, 140-141 Health Care Quality Improvement Act, 12 1- 122, 129 Health insurance, see Insurance Health Insurance Portability and Accountability Act (HIPAA) Read the entire page →
From page 279... ... see also Autopsies; Emergency departments; Infections and infection control; Intensive care units; Life Safety Code; Operating rooms; Risk management Hours of work, see Workload Human factors, 22, 53-54, 63-66, 145, 162-166, 170-173 aviation, 72 critical incident analysis, 63-64 defined, 63, 210 fatigue, 24, 42, 60, 163 human-machine interface, 62-63, 175 infusion pumps, case study, 50-66 naturalistic decision-making, 64 vigilance, 5, 158, 164, 170, 172 279 see also Cognitive processes; Error, general; Error analysis; Incompetent practitioners; Organizational factors Incompetent practitioners, 30, 36-37 negligent adverse events, 28, 30, 37, 114-131 organizational safety environment, 166, 169 public opinion, 42, 43 standards, 134, 142, 261 systems approach, 49 unlicensed, 261 see also Malpractice Infections and infection control, 30, 35, 42, 165, 267-268 Infectious diseases, 267-268 Information systems, 7, 74-75, 80-81, 177178, 180-181, 188-189, 195-196 clinical, 3 Internet, 92, 134 performance standards, 134, 138-139 role in errors, 61, 65 see also Computer systems; Confidentiality, reporting systems; Feedback; Media; Professional education; Public education; Reporting systems Infusion pumps, 50-51, 55-66 (passim) , 150, 171, 172, 183, 193, 255, 257 Institute for Healthcare Improvement, 183 Institute for Safe Medication Practices (ISMP) Read the entire page →
From page 280... ... , 71, 91, 93-94, 104105, 116, 125, 128, 138, 193, 194, 266 K Kansas, reporting system, 257-258 L Labeling, see Packaging and labeling, drugs Latent error, 55-56, 65, 66, 155, 181-182 Leadership, 69, 138, 156-157, 162, 166, 167, 168, 180-181, 197 authority gradient, 178, 180-181 committee recommendations, 6, 14, 69 see also Center for Patient Safety (proposed) INDEX Learning environment, 8, 23, 57, 62, 166, 178-182, 197 team training, 14, 79, 156, 170, 173174, 176-177, 179, 189, 197 see also Professional education Legal issues, 23 negligent adverse event, 28, 30, 37 see also Confidentiality, reporting systems; Liability issues; Litigation; Malpractice Legislation, in force Agency for Health Care Research and Quality, 78 Freedom of Information Act, 123 Health Care Quality Improvement Act, 121-122, 129 Health Insurance Portability and Accountability Act (HIPAA) Read the entire page →
From page 281... ... program, 95, 97, 100, 125, 126127, 194 MedMARx, 95,100, 126 MedWatch, 99, 123, 148-149 Memory, 54, 158, 163, 170, 171, 172, 185 checklists, 158,171,172,180,187, 194 simplification, 53, 60, 157, 158, 163, 164,166,170,171,172,185,197 see also Protocols 281 Mississippi, reporting system, 259 Models and modeling environmental influences on quality, 17-21 reporting hierarchy, 101 Mortality, x, 30, 31-32, 37, 221-223, 248249, 269 airline fatality rates, 5 anesthesia, 164, 222-225 drug errors, 28, 32-33, 42, 227, 229, 233, 248-249 infectious disease, 267-268 national, 1-2, 26, 27, 31, 248-249 reporting systems, 93, 96, 98, 101, 257, 258, 260, 262, 264 suicide, 35, 94, 257, 260, 262 Motivation, see Attitudes Multidisciplinary approaches, see Interdisciplinary approaches N Naloxone hydrochloride, 34 National Academy for State Health Policy, x, 92-93 National Aeronautics and Space Administration, 72, 96 Ames Research Center, 65, 73 Aviation Safety Reporting System (ASRS) , 72-73, 76, 91, 95-97, 104, 105-106, 125, 127 Challenger accident, 51, 52, 55 National Cancer Policy Board, 209 National Committee for Quality Assurance, 20, 138, 139 National Coordinating Council for Medication Error Reporting and Prevention, 183 National Fire Prevention Association, 267 National Forum for Health Care Quality Measurement and Reporting, 9, 10, 88, 89, 101, 103-104 National Institute for Occupational Safety and Health (NIOSH) Read the entire page →
From page 282... ... Navy Near-misses, 28, 87, 96, 101, 110, 127, 160, 177, 190; see also Errors, general New Jersey, reporting system, 260 New York State hospital studies, 1, 26, 30, 220-221, 238-239 outpatient surgery, 165 reporting system, 92, 124, 260-261 Norman, Donald, 163 Nuclear power industry, 60 Three Mile Island, 51, 52, 55 Nurses error studies, 216-217, 228-229, 232237, 243-245 infusion pumps, 50-51, 56 organizational accreditation, 138 professional accreditation, 143-144 reporting, 34, 256 Nursing homes, 2, 91, 209, 250-251, 254, 256 drug errors, 42 o Occupational health, 6-7, 24, 27, 73-74, 80, 159-162, 168 HEDIS, 20, 139, 140 INDEX National Occupational Research Agenda, 74 NIOSH, 73, 74, 82 patient safety and, 155-156 worker productivity losses, 2-3 workload, 24, 42, 60 Occupational Safety and Health Act, 73, 136 Occupational Safety and Health Administration, 73-74, 76, 90, 91, 97-98 Office of Post-Marketing Drug Risk Assessment (OPDRA) , 149, 150 Ohio, 261-262 Oklahoma, 128 Operating rooms, 31, 36, 50, 52, 56, 79, 157 Order entry systems, 33, 40, 62, 80, 172, 175, 183, 184-185, 188-189, 190, 191-192 Organizational factors, 3, 6-7, 13-14, 17, 22, 23, 60, 155-201, 266-271 access to health care, 24 accountability, 8, 13,101,166,167, 168, 205 authority gradient, 178, 180-181 culture of medicine, 21-22, 179 culture of safety, 12-13, 14, 155-156, 159-162, 166-168, 178, 179, 189 design for recovery, 176-177 drugs, 13,14,157-158,168,171, 172, 174, 175, 177, 182-197 error analysis, 8, 10, 166, 168 high reliability theory, 57 job design, 61, 62-63, 70, 170, 171, 172- 173, 176- 177 licensure and accreditation, 71, 103, 137-139, 151, 152, 168, 266 Joint Commission on Accreditation of Healthcare Organizations, 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266 reporting systems described, selected states, 255-265 (passim) Read the entire page →
From page 283... ... . Assoclatlon reporting systems, 10, 111, 112, 119 121, 126-128, 263-264 Pennsylvania, 262-263 Perrow, Charles, 51-52, 57, 60 Pew Health Professions Commission, 144 Pharmaceuticals, see Drugs Pharmacies, 2, 27, 32, 51, 183, 186-187, 192-193 283 Pharmacists, 2, 13, 27, 39, 145, 183, 186187, 193, 194- 195, 224-225, 230-233, 236-237, 240-245 reporting, 34 Physician order entry, see Order entry systems Physicians Desk Reference, 177 Phytonadione, 34 Pneumonia, 31, 220-221 Point-of-service plans, 139 Potassium chloride, 171, 187, 194 Practice guidelines, see Clinical practice guidelines Preferred provider organizations (PPOs) Read the entire page →
From page 284... ... , 70, 76, 79, 82 committee mission, xi, 205 patient education, 183, 188-189, 196197 see also Media Public opinion, 2, 29, 42-43, 70, 167 Punitive responses, 56, 157, 180, 197 Purchasers, 2, 3, 6, 11, 19-20, 23, 79, 152, 167, 206 organizational performance standards, 3, 139-141 reporting systems, 89 see also Health Care Financing Administration; Insurance Q Quality Improvement Organizations (QIOs) , 123; see also Peer . Read the entire page →
From page 285... ... . r punitive responses for reporting failures, 255, 258 sentinel events, 93-94, 104-105, 119120, 125, 128, 194 standards and standardization, 9, 2829, 73, 88-89, 99, 101-102, 104 state reporting systems, 254-265 surgery, 257, 263 285 voluntary, 8, 9-10, 23, 41-42, 79, 87, 89-90, 93-97, 98, 99, 102, 104106, 178, 179-180, 182, 188-189 confidentiality, 94, 95, 109-131, 256 litigation, 23, 109-131 Rhode Island, reporting system, 263-264 Risk management, general, 57, 58-59, 112, 137, 149, 270 see also High-risk industries s Safe Medical Device Act, 150-151 Sentinel events, 93-94, 104-105, 119-120, 125, 128, 194 Simplification, 53, 60, 157, 158, 163, 164, 166, 170, 171, 172, 185, 197 see also Protocols Simulation training, 65, 79, 145, 163, 176177, 178, 179 Software, see Computer systems South Dakota, reporting system, 264-265 Special Initiative on Health Care Quality, 208 Specialists and specialization, 3, 12, 20, 36, 58-59, 80, 142-143, 146, 148, 173 see also Anesthesia; Emergency departments; Intensive care units; Surgery; Teams Staffing, 138,166,167,170,172, 175-176, 190 ambulatory care, 165 Standards and standardization, 6, 9 adverse events taxonomies, 9, 10, 2829, 88 best practices, 9, 18, 32, 77, 79, 88, 93, 102-103, 145, 152, 182, 193 design for recovery, 176 devices and equipment, 23, 62, 144, 148-151, 156, 164, 172-173, 197 drugs, 13, 14, 23, 29, 171, 183, 184185, 190-191 environmental influences model, 19 Read the entire page →
From page 286... ... , 150, 171, 172 operatingrooms,31, 36,50, 52, 56, 79, 157 outpatient, 2, 165 postsurgical complications, 31-32 reporting systems, 257, 263 Switzerland, 177 INDEX Systems, general, 49, 50, 56-66, 71, 157, 158, 188-189, 190 aviation, 71-72 complex systems, 2, 36, 39, 53, 58-60, 61, 62-63, 65, 182-183 critical incident analysis, 63-64 defined, 52, 211 drugs, 182-183 redundancy, 57, 60, 158, 161-162 tightly coupled systems, 58-60, 161, 179 see also Error analysis; Feedback; Models and modeling; Organizational factors; Teams crew resource management, 79, 97, 147, 157, 161, 162, 173, 176, 179 patient as part of, 174 risk management, 270 technology as part of, 62-63 training in, 14, 79, 156, 170, 173-174, 176-177, 179, 189, 197 workingin,37, 50,51,56-57, 59, 60, 62-63, 64, 146-147, 166, 170, 197 Technological factors, 61-62, 80, 144, 159 anticipating new errors, 174-175 complexity, 36, 61, 62-63, 65 human-machine interface, 62-63, 175 professional licensing and, 135 protocols, updating of, 171 see also Computer systems; Devices and equipment; High-risk industries; Information systems Texas, 126-127 Three Mile Island, 51, 52, 55 Tiger teams, 175 Time-series measures, 182 see also Benchmarking Training, see Professional education Read the entire page →
From page 287... ... program, 95, 97, 100, 125, 126127, 194 Utah, hospital studies, 1, 26, 30-31, 36-37, 40, 238-239, 248-249 287 V Veterans Health Administration, 80, 83, 123 Vigilance, 5, 158, 164, 170, 172 Virginia, 142 W Workload, 24, 42, 60 World Wide Web, see Internet Wristbands, 177, 195 y Y2K issues, 82 Read the entire page →

From page 273...

... , 7-8, 69-71, 75-84, 135 Centers for Education and Research in Therapeutics, 77-78, 83 Consumer Assessment of Health Plans, 20 Aircraft carriers, 57, 160-161 Air transport, see Aviation Alaska, 142 Alcoa, Inc., 160 Allergic reactions, drugs, 33, 192 273

Index Pages 273-287

Index
Pages 273-287