Near-Miss Book


Book Description




Near Miss Reporting as a Safety Tool


Book Description

Near Miss Reporting as a Safety Tool arises from a meeting of safety professionals, academicians, and consultants from Western-Europe and Canada held in Eindhoven, the Netherlands, in September 1989. The book deals with near-miss reporting in various systems, mostly in the context of errors and accidents. The book begins by discussing the effects of bad management decisions in the design phase and a framework that will describe or manage these near misses through reporting, description, analysis, interpretation, and suggestions. Seven modules that compose this framework, called the Near Miss Management System (NMMS), along with pertinent cases, are explained. The book notes that near misses are ignored because of technical myopia, action-oriented organizations, event-focused organizations, consequence driven, and variables in quality of reporting. The organizational and management aspects of the NMMS are then analyzed within the commonly accepted culture and experience of the company. The book also presents comparative application of near miss information systems covering a wide range of industrial and transport environment. Such presentation allows differences and similarities to come into view more easily. The text will prove valuable for safety professionals in the nuclear and chemical industry and in road, railway, and air traffic management. Professors and students in safety management will likewise appreciate this book.




Safety Management


Book Description

Close calls, narrow escapes, or near hits. History has shown repeatedly that these "near-miss" incidents often precede loss producing events, but are largely ignored or go unreported because nothing (no injury, damage or loss) happened. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and




Patient Safety


Book Description

Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.




Near/Miss


Book Description

Praised in recent years as a “calculating, improvisatory, essential poet” by Daisy Fried in the New York Times, and as “the foremost poet-critic of our time” by Craig Dworkin, Charles Bernstein is a leading voice in American poetry. Near/Miss, Bernstein’s first poetry collection in five years, is the apotheosis of his late style, thick with off-center rhythms, hilarious riffs, and verbal extravagance. This collection’s title highlights poetry’s ability to graze reality without killing it, and at the same time implies that the poems themselves are wounded by the grief of loss. The book opens with a rollicking satire of difficult poetry—proudly declaring itself “a totally inaccessible poem”—and moves on to the stuff of contrarian pop culture and political cynicism—full of malaprops, mondegreens, nonsequiturs, translations of translations, sardonically vandalized signs, and a hilarious yet sinister feed of blog comments. At the same time, political protest also rubs up against epic collage, through poems exploring the unexpected intimacies and continuities of “our united fates.” These poems engage with works by contemporary painters—including Amy Sillman, Rackstraw Downes, and Etel Adnan—and echo translations of poets ranging from Catullus and Virgil to Goethe, Cruz e Souza, and Kandinsky. Grounded in a politics of multiplicity and dissent, and replete with both sharp edges and subtle intimacies, Near/Miss is full of close encounters of every kind.




Near Miss


Book Description

Displaced international consultant Dayle Standish heads for the Caribbean, following a losing battle involving corporate intrigue and blackmail. Diving Cozumel's azure waters, Dayle photographs a mysterious encounter inside a deep underwater cave. Soon after, a deadly assassin working for a foreign intelligence service starts targeting Cozumel dive operator Terry Manetta's customers. But Dayle is determined not to become the next victim, keeping one step ahead of a relentless killer pursuing her across the Atlantic and back to the Mexican Caribbean. Terry and her husband, former New York City detective Joe Manetta, team up with old friends at the NYPD, FBI, and CIA, to solve this international caper. Throw in the Washington DC PD and the alphabet soup gets even thicker, as spies, treasure hunters, and Cozumel scuba divers collide in this Caribbean adventure. It's been several years since Terry and Joe Manetta accidentally embroiled themselves in a Caribbean mystery thriller. Their latest adventure covers an international triangle anchored in New York City, Havana, and Cozumel with brief stopovers in Washington D.C., Madrid, and Cadiz.




Case Studies of Near Misses in Clinical Anesthesia


Book Description

All anesthesiologists eventually face the fear of a “near miss,” when a patient’s life has been put at risk. Learning from the experience is crucial to professionalism and the ongoing development of expertise. Drawing on forty-plus years of practice in major metropolitan hospitals in the United States, Norway, and South Africa, John Brock-Utne, MD presents 80 carefully selected cases that provide the basis for lessons and tips to prevent potential disaster. The cases emphasize problem-centered learning and span a broad range of topics—from an outbreak of operating room infection (could it be the anesthesia equipment?), complications of fiberoptic intubations, and problems with epidural drug pumps, to performing an urgent tracheostomy for the first time, working with an aggressive surgeon, and what to do when a patient falls off the operating table during surgery. 80 true-story clinical “near misses” never before published, ideal for problem-centered learning, recommendations, references, and discussions accompany most cases, rich basis for teaching discussions both in or out of the operating room, settings include sophisticated as well as rudimentary anesthetic environments, complements the author’s other case book, Clinical Anesthesia: Near Misses and Lessons Learned (Springer, 2008).




The Value of Close Calls in Improving Patient Safety


Book Description

Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems




The Curious Incident of the Dog in the Night-Time


Book Description

A bestselling modern classic—both poignant and funny—narrated by a fifteen year old autistic savant obsessed with Sherlock Holmes, this dazzling novel weaves together an old-fashioned mystery, a contemporary coming-of-age story, and a fascinating excursion into a mind incapable of processing emotions. Christopher John Francis Boone knows all the countries of the world and their capitals and every prime number up to 7,057. Although gifted with a superbly logical brain, Christopher is autistic. Everyday interactions and admonishments have little meaning for him. At fifteen, Christopher’s carefully constructed world falls apart when he finds his neighbour’s dog Wellington impaled on a garden fork, and he is initially blamed for the killing. Christopher decides that he will track down the real killer, and turns to his favourite fictional character, the impeccably logical Sherlock Holmes, for inspiration. But the investigation leads him down some unexpected paths and ultimately brings him face to face with the dissolution of his parents’ marriage. As Christopher tries to deal with the crisis within his own family, the narrative draws readers into the workings of Christopher’s mind. And herein lies the key to the brilliance of Mark Haddon’s choice of narrator: The most wrenching of emotional moments are chronicled by a boy who cannot fathom emotions. The effect is dazzling, making for one of the freshest debut in years: a comedy, a tearjerker, a mystery story, a novel of exceptional literary merit that is great fun to read.




Advances in Patient Safety


Book Description

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.