Keeping Patients Safe


Book Description

Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.




Safety Recommendation


Book Description




Aviation Safety and Pilot Control


Book Description

Adverse aircraft-pilot coupling (APC) events include a broad set of undesirable and sometimes hazardous phenomena that originate in anomalous interactions between pilots and aircraft. As civil and military aircraft technologies advance, interactions between pilots and aircraft are becoming more complex. Recent accidents and other incidents have been attributed to adverse APC in military aircraft. In addition, APC has been implicated in some civilian incidents. This book evaluates the current state of knowledge about adverse APC and processes that may be used to eliminate it from military and commercial aircraft. It was written for technical, government, and administrative decisionmakers and their technical and administrative support staffs; key technical managers in the aircraft manufacturing and operational industries; stability and control engineers; aircraft flight control system designers; research specialists in flight control, flying qualities, human factors; and technically knowledgeable lay readers.




To Err Is Human


Book Description

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine










Safe Science


Book Description

Recent serious and sometimes fatal accidents in chemical research laboratories at United States universities have driven government agencies, professional societies, industries, and universities themselves to examine the culture of safety in research laboratories. These incidents have triggered a broader discussion of how serious incidents can be prevented in the future and how best to train researchers and emergency personnel to respond appropriately when incidents do occur. As the priority placed on safety increases, many institutions have expressed a desire to go beyond simple compliance with regulations to work toward fostering a strong, positive safety culture: affirming a constant commitment to safety throughout their institutions, while integrating safety as an essential element in the daily work of laboratory researchers. Safe Science takes on this challenge. This report examines the culture of safety in research institutions and makes recommendations for university leadership, laboratory researchers, and environmental health and safety professionals to support safety as a core value of their institutions. The report discusses ways to fulfill that commitment through prioritizing funding for safety equipment and training, as well as making safety an ongoing operational priority. A strong, positive safety culture arises not because of a set of rules but because of a constant commitment to safety throughout an organization. Such a culture supports the free exchange of safety information, emphasizes learning and improvement, and assigns greater importance to solving problems than to placing blame. High importance is assigned to safety at all times, not just when it is convenient or does not threaten personal or institutional productivity goals. Safe Science will be a guide to make the changes needed at all levels to protect students, researchers, and staff.










NIH Publication


Book Description