Patient Safety Basics

Patient safety is a relatively new health care discipline that clearly emphasizes the reporting, analysis, and prevention of all types of medical errors that frequently result in adverse health care events. The Institute of Medicine in the United States defines patient safety as the prevention of harm to patients [1,2]. 

The occurrence, frequency, and magnitude of avoidable adverse patient-related events were not well known until the 1990s, when a number of countries reported staggering numbers of patient harm and deaths due to human errors. For example, the United States lost more American lives to patient safety-associated adverse events every 6 months than it did during the entire Vietnam War [3]. 

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Chapter 3 presents introductory aspects of safety and human factors. Chapter 4 is devoted to methods considered useful to perform patient safety analysis. These methods include failure modes and effect analysis (FMEA), fault tree analysis (FTA), root cause analysis (RCA), hazard and operability analysis (HAZOP), six sigma methodology, preliminary hazard analysis (PFfA), interface safety analysis (ISA), and job safety analysis (JSA). Patient safety basics are presented in Chapter 5. This chapter covers such topics as patient safety goals, causes of patient injuries, patient safety culture, factors contributing to pahent safety culture, safe practices for better health care, and patient safety indicators and their selection. 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

Patient safety is a basic attribute of healthcare systems it minimizes the incidence and impact of, and maximizes recovery from, adverse events [4],... 

Introduction Basic Amplifier Requirements Isolation Amplifier and Patient Safety Surge Protection Input Guarding Dynamic Range and Recovery Digital Electronics Summary Defining Terms References Further Information... 

A second reason is that for all the books, reports, articles and Websites devoted to patient safety, there is still no straightforward overview of the field. The books that are available are mostly multi-author edited texts which, while they bring a rich diversity of perspective, are not primarily aimed at explaining the basic principles, characteristics and direction of the field. My aim has been to show the landscape of patient safety how it evolved, the research that underpins the area, the key conceptual issues that have to be addressed, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved. 

In conclusion, this chapter demonstrates that the IRT approach can provide additional insights to psychometric properties of the HSOPSC. Both, the classical and modem approaches, are needed to form a complete picture of the properties of a set of items. Understanding the basic principles of IRT will hopefully foster its use more widely within the field of patient safety culture assessment. This will ultimately enhance our ability to measure this important constmct accurately. 

In 2003 the National Quality Forum in the United States endorsed a total of 30 patient safety-related safer practices that should be implemented throughout clinical care settings to lower the risk of error and resultant harm to patients in general [20,21]. The first safer practice (i.e.. Create and sustain a health care culture of safety) was composed of the following four basic components [20,21] ... 

Improved laboratory information processing enabled by health information exchange can improve patient safety. Two basic areas for this are helping to ensure that lab testing imder consideration is ordered and helping to ensure that lab test results are properly followed up on. 

This chapter introduces the fundamental concepts of patient safety. Research underlying the basic concepts of patient safety comes from outside health care, primarily from engineering, aviation, psychology, and sociology. These areas of inquiry replace the impoverished conceptualization of error reduction with the more robust concept of complex adaptive systems. The framing principles are ... 

As a participant in his hospital s patient safety initiative, pediatric emergency physician Tom Hellmich attended several educational sessions where he learned about basic concepts in safety, such as hindsight bias and the Swiss Cheese Model. The lessons proved useful during a particularly busy week at work. In one day, two children, one in the hospital s emergency department and the other in an inpatient unit, suffered a cardiac arrest, requiring a code to be called. 

Reason, J. T. The Basics of Human Eactors. Paper presented at the Salzburg International Seminar on Patient Safety and Medical Accident, Apr. 25-May 2, 2001. 

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