Patient safety topics

The question arises of whether the views of patients should be used routinely as a source of patient safety topics. For example, as well as being asked neutral questions about their experiences during their hospital stay, patients could perhaps also be asked directly whether they notieed any errors or incidents that they consider to be relevant or prejudicial to patient safety (Wasson et al. 2007). 

Some compendial requirements have been instituted to guide packaging practices for drugs that are characterized by their route of administration. These guidelines are designed to enhance patient safety and prevent undesirable outcomes. The administrative modes discussed here include oral, parenteral, and topical. 

Another aspect of patient safety is related to the relatively low risk of accidental phototoxic reactions in the days and weeks following ALA-PDT. When the ALA is applied topically, photosensitization is not generalized but is restricted to the site of treatment. Also, since the PpIX is photobleached during the treatment and any residual PpIX is rapidly cleared from the body, most patients can safely expose themselves to sunlight 24 h after treatment. 

People, organizations and culture vary enormously in their approaches and response to error and attitudes to error are changing. Hopefully, as patient safety evolves, healthcare staff will be able to be more open about error and more open about their need for support when errors do occur. While there is little formal guidance, and almost no research on this topic, the following suggestions may be useful. 

Why though, even if you accept this perspective, should you read a book on patient safety The first reason is very simple the importance of the topic. As you will see if you read on, there is compelling evidence that, while healthcare brings enormous benefits to us all, errors are common and patients are frequently harmed. The nature and scale of this harm is hard to comprehend. It is made up, worldwide, of hundreds of thousands of individual tragedies every year, in which patients are traumatized, suffer unnecessary pain, are left disabled or die. Many more people have their care interrupted or delayed by minor errors and problems these incidents are not as serious for patients but are a massive and relentless drain on scarce healthcare resources. 

Third, patient safety is a meeting point for a multitude of other topics. The relevant literature is difficult to grasp, being scattered, diverse and multidisciplinary in nature. Much of it is published in areas, such as cognitive psychology and ergonomics, which are unfamiliar to medicine. Worse still, many of the topics fundamental to progress in patient safety are themselves the subjects of... 

Individual reports such as that of Mrs L. can also be of value to the attending healthcare professionals. Where, as in the ease outlined above, an elderly patient states explicitly that questions that are important to her have been left unanswered and that she felt inadequately eared for on diseharge, this can serve as a stimulus to the healthcare professionals eoncemed to pay eloser attention to these points in other patients. This is because individual reports of this kind give a face to abstract descriptions of problems and raise awareness of the topic of patient safety among healthcare professionals. 

Over the years a large number of journal and conference proceedings articles on patient safety have appeared, but there are only a small number of books on the topic. In fact, to the best of the author s knowledge, there is no book that reflects a comprehensive review of published journal and conference proceedings articles on the topic and considers methods and techniques developed in the area of engineering to handle safety and human error-related problems. This causes a great deal of difficulty to information seekers on the subject, because they have to consult many different and diverse sources. 

The topics covered in the volume are treated in such a manner that the reader requires no previous knowledge to understand the contents. At appropriate places the book contains examples along with their solutions, and at the end of each chapter there are numerous problems to test reader comprehension. A comprehensive list of references covering the period 1967-2011 on patient safety is provided in the appendix, to give readers a view of the intensity of developments in the area. 

The book is composed of 11 chapters. Chapter 1 presents the various introductory aspects of patient safety including patient safety-related facts and figures, terms and definitions, and sources for obtaining useful information on patient safety. Chapter 2 reviews mathematical concepts considered useful to understand subsequent chapters and covers topics such as mode, median, mean deviation. Boolean algebra laws, probability definition and properties, Laplace transforms, and probability distributions. 

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. 

Chapter 10 is devoted to medical device usability. It covers topics such as medical device users and use environments, medical device user interfaces, an approach to develop medical devices effective user interfaces, guidelines to reduce medical device user interface-related errors, guidelines for designing hand-operated devices with respect to cumulative trauma disorder, and useful documents for improving usability of medical devices. Chapter 11 presents three important topics relating to patient safety patient safety organizations, data sources, and mathematical models for performing probabilistic patient safety analysis. 

When unit-based safety groups, policy review committees, performance improvement groups, or individual managers or executives want to tap in to the collected wisdom of the organization s safety reports, they request a topic search from the Office of Patient Safety. Accessing the safety search engine, staff members retrieve a stack of reports related to the requested topic, and these can be used to inform local innovations and improvements. 

Because patient safety is a complex multidisciplinary topic, it is recommended that each health care organization establish a multidisciplinary team to complete a single Patient Safety Organizational Assessment Tool. The team should consist... 

Hospital Survey on Patient Safety Culture Comparative Database Reports give benchmark data collected voluntarily from more than 1000 US hospitals. Survey results from these hospitals are averaged over the entire sample by topical composite or individual survey item. Two appendices report the average responses, which are broken down by hospital or respondent characteristics. 

Advances in Patient Safety New Directions and Alternative Approaches is a four-volume set of 115 articles, which describe patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools to prevent patients from being harmed. It includes articles by AHRQ-funded patient safety researchers on topics such as reporting systems, risk assessment, safety culture, medical simulation, health information technology, and medication safety (AHRQ Publication No. 08-0034). 

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