To Do No Harm : Ensuring Patient Safety in Health Care Organizations by Julianne M. Morath, Joanne E. Turnbull, Lucian L. Leape (Jossey-Bass) With this important resource, health care leaders from the board room to the point-of-care can learn how to apply the science of safe and best practices from industry to healthcare by changing leadership practices, models of service delivery, and methods of communication.
Julianne M. Morath is the chief operating officer and vice president of care delivery of Children's Hospitals and Clinics in Minneapolis - St. Paul, Minnesota. She is a board member of the National Patient Safety Foundation in Chicago, Illinois.
Joanne E. Turnbull, RN, MS, is a well-known writer and speaker on the subject of patient safety. Until 2001 she was the executive director of the National Patient Safety Foundation.
Excerpt: To Do No Harm is relevant to leaders in all health care disciplines today: senior health care executives, medical directors, nurse executives, pharmacy leaders, patient care managers, quality and risk professionals, and leaders of clinical disciplines as well as board members. The content is applicable to any health care setting: hospital inpatient services, emergency services, acute care, rehabilitation services, nursing homes, home health services, and ambulatory services ranging from physicians' offices to infusion and surgery centers. The wide applicability of the book's content is in keeping with the principle that care is provided through a complex system of sites, services, and relationships, and that we can create safety only by understanding relationships, communicating effectively, anticipating gaps in patient safety, and acting collectively to close or bridge them. This book is also for the leaders of tomorrow: graduate-level students in the disciplines just mentioned, and those who have embraced the vision embodied in these pages and plan to make the field of patient safety their career focus.
The chapters in this book are structured around the patient safety manifesto developed at the Harvard Executive Session on Medical Error and Patient Safety. The Executive Session brought together senior leaders in health care from around the nation to examine the failures in current health care models and to develop models of health care delivery that do no harm (see the Introduction and Chapter Nine for further information on the Harvard Executive Session). Leaders emerged with a seven-point manifesto for creating a system of harm-free care. With the exception of Chapters Two and Three, which provide basic information about the science of patient safety, and Chapter Ten, which recaps the lessons offered by the book as a whole, the titles of the chapters are the same as the seven commitments of the manifesto:
Chapter One, "Declare Patient Safety Urgent and a Priority," explores the patient safety manifesto's first challenge to leadership. The chapter discusses how
and why to develop and create a vision and a platform for patient safety in your organization.
Chapter Two, "Error and Harm in Health Care," departs momentarily from the patient safety manifesto, as already mentioned, to provide background knowledge on current research in patient safety the patient safety movement to date, and the reasons why today's health care system is so error-prone.
Chapter Three, "Understanding the Basics of Patient Safety," provides an overview of basic concepts and terms in the science of patient safety. These concepts and terms form the foundational touchpoints of the book. Chapter Four, `Assume Executive Responsibility," returns to the commitments embodied in the patient safety manifesto. It hones in on the leader's role in making the commitment to create harm-free care, outlines the specific characteristics of the leader's role in safety, and discusses the leader's responses to error.
Chapter Five, "Import New Knowledge and Skills," translates concepts from safety science and lessons from high-reliability organizations into practical applications for health care.
Chapter Six, "Install a Blameless Reporting System," is devoted to the design and implementation of voluntary reporting systems, an indispensable feature of the safety culture. The chapter presents the rationale for developing an internal voluntary reporting system, and it offers an overview of the successful use of such a system in the field of aviation and beginning efforts in health care. Chapter Six also discusses the voluntary reporting system as a management decision-support tool and a tool for culture change, and it addresses legal concerns and other barriers to a blameless reporting system.
Chapter Seven, `Assign Accountability" addresses issues of management and front-line responsibility in the context of safety, and within a systems perspective. Chapter Eight, `Align External Controls and Reform Education," focuses on the need to bring such external forces as academic, legal, and regulatory systems into alignment, since external forces can help or hinder a systems approach to health care safety.
Chapter Nine, `Accelerate Change," discusses methods and techniques for accelerating and sustaining change.
Chapter Ten, "The End of the Beginning," concludes the book with a review of lessons learned and challenges for advancing the work of patient safety.
The book also includes a glossary of terms used frequently in patient safety science. Starting in the Introduction, the first time we use one of these terms, it appears in boldface type. A list of references is provided along with resources in-
tended to encourage and guide further education in patient safety. Finally, the glossary is followed by a series of appendixes containing examples of policies, projects, tools, and other items helpful in beginning and sustaining a patient safety initiative.
The book follows a logical sequence, moving from general information (re-search, background, safety science) about patient safety in health care to more specific and practical aspects of implementation (the safety culture, voluntary reporting systems, the leader's role, and training). Accordingly, reading the book in a linear fashion will offer the most comprehensive picture of patient safety, but each chapter also stands on its own, so a particular topic can be selected for reference.
This primer is a succinct yet comprehensive resource on patient safety for today's busy health care leader. It summarizes key research, with an emphasis on what the findings mean for practice. It translates the concepts of safety science into practical applications, and it captures learning from failures as well as from "best practices" that are emerging from the work of leaders who are testing new models for patient safety. Action strategies are presented along with precepts of safety science so that both can be integrated into health care operations, and so that leaders can develop the necessary skills to lead a culture of safety. Throughout the book, we strive to be mindful of the demands on our readers' time, summarizing existing knowledge and mapping lessons from other fields in a succinct, practical way. Case studies, labeled "Concept to Action," pro-vide examples of good practice and contribute to our effort to make the material relevant.
The goals of this practical guide are to teach the science of safety, introduce the lessons that other high risk industries can teach us, present ways to learn from health care's failures and successes, and examine the growing body of better practices and achievable, effective initiatives that can help transform the concepts of patient safety into action.
Research and new applications of safety science in health care are increasing exponentially. To meet our publication deadlines, we concluded our own research in April 2003. Had we not done so we would still be writing, as new lessons emerge daily. We encourage you to keep abreast of new activities in the field by using the organizations and Web sites listed in the Resources section.
Changing the culture of the organization is the key to creating and sustaining patient safety, and the leader's role is the crucial feature. Therefore, the heart of the effort represented by this book is the effort to help leaders move their organizational cultures from blame, shame, and cover-up to vigilance, transparency, and learning. Only culture change will create an environment devoted to and
equipped for harm-free care. Health care leaders need a new competency for this challenge—knowledge of patient safety—together with deep integrity and unflappable vision. Taken together, these attributes will enable a leader to call the existing culture into question and expose the myths that operate within it. The goal is to empower the health care leader to create, lead, and sustain a new culture—a culture of safety.
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