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| Foreword | |
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| Acknowledgments | |
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| Contributors | |
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| Key Concepts in Patient Safety | |
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| Safety as a Foundation of High-Quality Health Care | |
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| The Case for Improving Patient Safety | |
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| Risky Systems and Normal Accidents | |
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| Risk Analysis, Public Policy, and Regulation | |
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| Important Governance and Organizations in Patient Safety | |
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| Basic Concepts of Patient Safety | |
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| Taxonomy, Definitions, and Terms | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Appendix | |
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| Keeping the Patient Safe | |
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| Patient Safety in Health Care | |
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| Patient's Bill of Rights | |
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| The Patient Experiences Gaps in Continuity of Care | |
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| Relationship Between the Patient and the Healthcare Practitioner | |
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| Patient Expectations | |
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| Patients' Experiences with Safety | |
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| Advocates for the Patient-Someone to Watch Over You | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Safety Improvement Is in Professional Practice | |
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| The Professions: Roles, Scopes of Practice, and Educational Prepatation | |
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| Patient Safety Addressed in Professional Codes and Profession-Specific Literature | |
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| Patient Safety and Interprofessional Collaboration | |
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| Concept of The "Team" in Safe Practice | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Safety Improvement Is in Systems | |
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| Safety in Systems | |
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| Systems | |
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| Improper Decision Analysis in Studies of Positron Emission Tomography | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Safety Improvement Is Achieved Within Organizations | |
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| Dilemma of Conflicting Priorities | |
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| Medical Errors from an Organizational Perspective | |
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| Implications of an Organizational Perspective | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Appendix | |
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| Todays Action | |
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| The Final Rule | |
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| How Would It Wotk? | |
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| Other Benefits | |
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| Culture of Safety in Healthcare Settings | |
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| The Concept of Culture | |
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| What Is a Culture of Safety? | |
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| The Ideal Safety Culture | |
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| Reaction to Errors | |
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| Blame-Free Culture Versus Just Culture | |
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| Measuring the Culture of Safety in Hospitals | |
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| Changing to a Safety Culture-Top Down and Bottom Up | |
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| Strategies and Tools for Changing to a Culture of Safety | |
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| TeamSTEPPS: Tools for a Culture of Safety | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Why Things Go Wrong | |
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| Errors, Mistakes, and Accidents | |
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| Human Error | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| What to Do When Things Go Wrong | |
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| Best Practices for Error Disclosure | |
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| Reporting Errors | |
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| The Legal System | |
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| Tort Law | |
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| Whistleblowing and Its Implications | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Safe Patient Care Systems | |
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| Improvements in Patient Safety | |
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| The Science of Safe Systems | |
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| A Systems Context for Safety | |
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| Quality and Patient Safety | |
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| Total Quality Management | |
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| Continuous Quality Improvement | |
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| The Joint Commission, Patient Safety Coalitions and Safety Improvement | |
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| Components of a Comprehensive Quality Management Program | |
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| CQI-How It Works: A Practical Example | |
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| CQI and a Major Adverse Event | |
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| Patient Involvement in Quality Improvement | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Appendix | |
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| The Use of Evidence to Improve Safety | |
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| What Constitutes Evidence in Safety? | |
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| When to Use Methods of High Rigor | |
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| Evidence in Safety: An Alternative View | |
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| Using Evidence to Affect Patient Safety | |
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| Summary | |
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| A Closing Case | |
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| References | |
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| Taxonomy of Terms and the Source | |
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| Index | |