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<p>Figures, Tables, and Exhibits v</p> <p>Foreword ix<br /><i>Lucian L. Leape</i></p> <p>Preface xi</p> <p>The Editor xvii</p> <p>The Authors xix</p> <p><b>PART ONE: The Basics of Patient Safety</b></p> <p>Chapter 1 A Formula for Errors: Good People + Bad Systems 3<br /><i>Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin</i></p> <p>Chapter 2 The Human Side of Medical Mistakes 21<br /><i>Sven Ternov</i></p> <p>Chapter 3 High Reliability and Patient Safety 35<br /><i>Yosef D. Dlugacz and Patrice L. Spath</i></p> <p><b>PART TWO: Measure and Evaluate Patient Safety</b></p> <p>Chapter 4 Measuring Patient Safety Performance 59<br /><i>Karen Ferraco and Patrice L. Spath</i></p> <p>Chapter 5 Analyzing Patient Safety Performance 103<br /><i>Karen Ferraco and Patrice L. Spath</i></p> <p>Chapter 6 Using Performance Data to Prioritize Safety Improvement Projects 119<br /><i>Robert Latino</i></p> <p><b>PART THREE: Reactive and Proactive Safety Investigations</b></p> <p>Chapter 7 Accident Investigation and Anticipatory Failure Analysis 143<br /><i>Sanford E. Feldman and Douglas W. Roblin</i></p> <p>Chapter 8 MTO and DEB Analysis Can Find System Breakdowns 157<br /><i>Sven Ternov</i></p> <p>Chapter 9 Using Deductive Analysis to Examine Adverse Events 171<br /><i>Robert Latino</i></p> <p><b>PART FOUR: How to Make Health Care Processes Safer</b></p> <p>Chapter 10 Proactively Error-Proofing Health Care Processes 197<br /><i>Richard J. Croteau and Paul M. Schyve</i></p> <p>Chapter 11 Reducing Errors Through Work System Improvements 217<br /><i>Patrice L. Spath</i></p> <p>Chapter 12 Improve Patient Safety with Lean Techniques 245<br /><i>Danielle Lavallee</i></p> <p><b>PART FIVE: Focused Patient Safety Initiatives</b></p> <p>Chapter 13 How Information Technology Can Improve Patient Safety 269<br /><i>Donna J. Slovensky and Nir Menachemi</i></p> <p>Chapter 14 A Structured Teamwork System to Reduce Clinical Errors 297<br /><i>Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey</i></p> <p>Chapter 15 Medication Safety Improvement 335<br /><i>Yosef D. Dlugacz</i></p> <p>Glossary 369</p> <p>Index 383</p>

<p>Patrice L. Spath, MA, RHIT, is president of Brown-Spath & Associates and assistant professor in the Department of Health Services Administration at the University of Alabama in Birmingham. She serves on the advisory board for WebM&M, an online case-based journal and forum on patient safety and health care quality sponsored by the Agency for Healthcare Research and Quality. Spath has authored numerous books and journal articles on health care performance improvement and patient safety.</p>

<p>Error Reduction in Health Care</p> <p>Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur.</p> <p>With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors.</p> <p>This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.</p> <p>The Editor</p>

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