Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition
February 2011, Jossey-Bass
Error Reduction in Health Care
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.
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.
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.
Foreword (Lucien L. Leape).
PART ONE The Basics of Patient Safety.
1: A Formula for Errors  Good People + Bad Systems (Susan McClanahan, Susan T. Goodwin, and Jonathan B. Perlin).
2: The Human Side of Medical Mistakes (Sven Ternov).
3: High Reliability and Patient Safety (Yosef D. Dlugacz and Patrice L. Spath).
PART TWO Measure and Evaluate Patient Safety.
4: Measuring Performance of High-Risk Processes (Karen Ferraco and Patrice L. Spath).
5: Analyzing Patient Safety Performance (Karen Ferraco and Patrice L. Spath).
6: Using Performance Data to Prioritize Safety Improvement Projects (Robert Latino).
PART THREE Reactive and Proactive Safety Investigations.
7: Accident Investigation and Anticipatory Failure Analysis
Sanford E. Feldman and Douglas W. Roblin
8: MTO and DEB Analysis Can Find System Breakdowns (Sven Ternov).
9: Using Deductive Analysis to Examine Adverse Events (Robert Latino).
PART FOUR How to Make Health Care Processes Safer.
10: Proactively Error-Proofing Health Care Processes (Richard J. Croteau and Paul M. Schyve).
11: Reducing Errors Through Work Systems Improvements (Patrice L. Spath).
12: Improve Patient Safety with Lean Techniques (Danielle Lavallee).
PART FIVE Focused Patient Safety Initiatives.
13: How Information Technology Can Improve Patient Safety (Donna J. Slovensky and Nir Menachemi).
14: A Structured Teamwork System to Reduce Clinical Errors (Daniel T. Risser, Robert Simon, Matthew M. Rice, Mary L. Salisbury, and John C. Morey).
15: Medication Safety Improvement (Yosef D. Dlugacz).
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.