Patient Safety and Risk Management in Medicine - From Theory to Practice (Jan 30, 2024)_(303149864X)_(Springer)

Preface
	Medical Risk Management and Patient Safety
		Introduction
Acknowledgments
Contents
List of Figures
List of Tables
About the Authors
1: Risks and Adverse Events in Medicine
	1.1	 What Is Risk?
	1.2	 What Is an Adverse Medical Event?
	1.3	 Results of an Adverse Event: Severity of Damage
	1.4	 Adverse Events According to Medical Specialties
	1.5	 Adverse Events According to the Nature of the Event
	1.6	 Preventable and Nonpreventable Adverse Events
	References
2: The Scope of Iatrogenic Harm
	2.1	 The Scope of the Iatrogenic Harm Phenomenon
	2.2	 Causes of the Nonreporting of Medical Errors
	References
3: Development of Patient Safety and Risk Management in Medicine
	3.1	 Definitions
	3.2	 What Are the Differences Between Safety, Risk Management, and Quality
	3.3	 Importance of Risk Management
	3.4	 History of Risk Management
	3.5	 Motivation to Engage in Risk Management Activities
	3.6	 Effect of the Economic Crisis in 2008 on the Perception of the Importance of Risk Management
	References
4: Safety Culture and Its Improvement in a Medical Organization
	4.1	 Development of the Concepts “Organizational Safety Culture” and “Safety Climate”
	4.2	 Safety Culture in Medicine
	4.3	 Typology of Safety Culture
	4.4	 How to Measure Safety Culture in a Medical Environment
	4.5	 How to Improve Safety Culture
	References
5: The Human Factor: Human Errors in Medicine
	5.1	 What Are Human Errors?
	5.2	 Causes of Human Error
	5.3	 Typology of Human Errors
	5.4	 Therapist and His Influence on Errors in Medical Treatment
	5.5	 Reducing the Probability of Human Error
	References
6: Organizational Factor in Patient Safety and Risk Management
	6.1	 Position of Regulators Regarding Risk Management Activities in Health Institutions
		6.1.1	 Types of Activities During an Epidemic (in Continuous Cooperation with the Infection Prevention Unit)
		6.1.2	 The Israeli Pilot Act 2012: An Example of Risk Management and Safety Culture
		6.1.3	 Laws Dealing with the Regulation of Treatment Safety Promotion Activities in the USA, Denmark, and Italy
		6.1.4	 Human Resource Management: Recruitment and Training
	6.2	 Effect of the Work Environment on the Quality of Care: Aspects of Human Engineering
		6.2.1	 There Are Five Types of Ergonomics: Physical, Specific Needs, Cognitive, Corrective, and Preventive
		6.2.2	 Solutions to Reduce Physical Damage Include the Following
		6.2.3	 Changing the Work Environment
		6.2.4	 Ergonomic Solutions to Reduce Errors
		6.2.5	 Work Environment Has a Significant Impact on Medication Safety in the Following Areas
		6.2.6	 There Is a Need for Built-in Control Processes Within the Patient’s Computerized Record Related to, For Example
		6.2.7	 Surry Model to Prevent Operational Failure (Fig. 6.4)
	6.3	 Information Systems and Organizational Computing and Their Effect on Treatment Safety
	6.4	 Managers’ References to Safety Culture and Adverse Events
	6.5	 Continuity of Care: Work Interfaces Between Treatment Factors Inside and Outside the Health Organization
	6.6	 Activity to Promote Quality Versus Risk Management Activity and Treatment Safety
	6.7	 Regulation and Accreditation
		6.7.1	 IPSG Standards Are as Follows
		6.7.2	 In Addition to IPSG Standards, Safety Standards and Required Measurable Elements Appear in Each of the 14 Chapters of the JCI Book
	6.8	 Dedicated Information Systems for Risk Management and Treatment Safety
	6.9	 Risks in Computerized Medical Record Management
		6.9.1	 Existence of a Computerized Medical File Is a Cornerstone in the Provision of Quality and Safe Medical Service and Especially in Six Key Elements That It Enables
	6.10	 Risk Management of Online Medicine
	6.11	 Risk Management of External Suppliers
		6.11.1	 Medical Institution Is Responsible for Every Operation Performed on Its Patients Under Its Roof; Therefore, There Are Several Requirements When Contracting with an External Provider [24]
	6.12	 Procurement and Logistics Risk Management
	References
7: Errors in Medication Administration
	7.1	 Characterization, Types of Errors, and the Scope of the Phenomenon
	7.2	 Causes of Errors in the Medication Administration Process
		7.2.1	 Common Examples of Medication Administration Errors
	7.3	 How to Reduce Errors in the Medication Administration Process
		7.3.1	 For Each Medicine, Observe Seven “Correct” Moves (7 Rights)
	7.4	 Polypharmacy: Consequences and Means of Reduction
	References
8: Medico-Legal Aspects of Patient Safety and Risk Management
	8.1	 What Is Medical Malpractice, and How Is It Determined?
		8.1.1	 Concept of Punishment for Medical Errors, Concept of Compensation, and the Alternative of “No-Fault”
	8.2	 Harm in Medical Malpractice
		8.2.1	 Subjects and Objects of the Claim
		8.2.2	 Examples of Verdicts in Israel and the USA (Table 8.2)
	8.3	 Legal Investigation Procedure for a Negligence Claim
	8.4	 Interplay Between the Legal System and Risk Management and Patient Safety
	8.5	 What Are Patient Rights Laws and What Are Their Implications for Risk Management Activities and Patient Safety?
		8.5.1	 Patient Rights Laws Generally Include the Following 12 Principles
		8.5.2	 Examples of Ruling in Negligence Claims
		8.5.3	 Perception of Negligence Cases in the Eyes of the Court
	8.6	 Informed Consent
		8.6.1	 Duty of Follow-up
		8.6.2	 Obligation to Transfer Information
		8.6.3	 Obligation to Accurately Record a Referral or Test Result
		8.6.4	 Confidentiality of Investigations and Protocol of Examination Committee Discussions
	8.7	 Legal Aspects in OECD Countries
	References
9: Medical Professional Liability Insurance
	9.1	 Principles of Risk Transfer by the Insurer
	9.2	 The Israeli Method
	9.3	 The Scandinavian Method
	References
10: Patient as a Partner in Promoting Patient Safety
	10.1	 Introduction
	10.2	 Challenge of Patient Participation
	10.3	 Patients Differ
	10.4	 Patient as a Factor Affecting the Success and Safety of Treatment
	10.5	 Results of Patient Nonparticipation in the Therapeutic Process
	10.6	 Caregiver-Patient Relationship and Communication
	10.7	 Obstacles and Challenges in Patient Participation
	References
11: Risk Management and Patient Safety Processes in a Healthcare Organization
	11.1	 Introduction: Three Approaches to Promoting Patient Safety
	11.2	 Reactive Risk Management Activities
		11.2.1	 Reporting of Adverse Events
		11.2.2	 Benefits for the Caregiver
		11.2.3	 Advantages of the Organization
		11.2.4	 Benefits for the Patient
		11.2.5	 Principles in Establishing a Reporting System for Adverse Events
		11.2.6	 Why Should a Caregiver Report? Direct and Indirect Benefits
	11.3	 Safety Investigations of and Lessons Learned from Adverse Events
		11.3.1	 Types of Investigations and Their Characteristics
		11.3.2	 Criteria for Selecting an Adverse Event for Investigation
		11.3.3	 Decision to Carry Out an Investigation
		11.3.4	 Appointment of the Safety Investigation Team
		11.3.5	 Steps in a Safety Investigation
	11.4	 Introduction to Interactive Risk Management Activities
		11.4.1	 Support for Caregivers Involved in Adverse Events (The Second Victim)
	11.5	 Disclosure of Medical Errors
	11.6	 Introduction to Proactive Risk Management Activities
		11.6.1	 How Can a Topic Be Chosen for a Proactive Activity?
		11.6.2	 Advantages of Proactive Risk Management
	11.7	 Defining Patient Safety and Risk Management Policy in a Medical Organization
	11.8	 Annual Work Plan for Promoting Patient Safety and Risk Management
	11.9	 Safety Rounds in a Medical Institution: Principles and Application
		11.9.1 Principles for Performing Safety Rounds
	11.10	 Patient Safety Training and Education
	Appendixes
		Appendix A: Investigation Report Template and Common Mistakes in Writing an Investigation Report
		Appendix B: An Example of the Policy Format for Risk Management and Patient Safety
			The “Safe Health” Company’s Risk Management and Patient Safety Policy
		Appendix C: An Example of an Annual Work Plan for Risk Management and  Patient Safety
		Appendix D: A Format for Conducting Safety Rounds in a Medical Institution
			Part A: Opening Discussion
			Part B: Observations
			Part C: Interviewing Staff Members in the Unit
			Part D: Conclusion
	References
12: Evaluation and Measurement of Risk Management Activity and Patient Safety
	12.1	 The Importance of Measuring the Quality and Effectiveness of Risk Management and Patient Safety Activities
	12.2	 Defining Indicators for the Quality of the Risk Management Activity and Treatment Safety
	References
13: Patient Safety and Risk Management Organizations and Institutions
	13.1	 International Organizations
		13.1.1	 WHO: World Alliance for Patient Safety
		13.1.2	 ISQUA: The International Society for Quality in Health Care
		13.1.3	 OECD: Patient Safety
	13.2	 US Organizations
		13.2.1	 IOM (Institute of Medicine): NAM (National Academy of Medicine)
		13.2.2	 JCI (Joint Commission International)
		13.2.3	 IHI (Institute of Healthcare Improvement)
		13.2.4	 NPSF (National Patient Safety Foundation)
		13.2.5	 AHRQ (Agency for Healthcare Research and Quality)
		13.2.6	 ASHRM (American Society for Healthcare Risk Management)
		13.2.7	 ECRI (Emergency Care Research Institute)
	13.3	 European Organizations
		13.3.1	 NHS
	13.4	 Israeli Organizations
		13.4.1	 NASBAR: The Israeli Society for Patient Safety and Risk Management in Medicine [38]
		13.4.2	 The Israeli Society for Quality in Medicine [39]
		13.4.3	 Madanes: Insurance Agency [40]
		13.4.4	 Inbal: An Insurance Company [41]
		13.4.5	 The Division for Quality and Patient Safety: MOH [44]
	13.5	 ASRS: Aviation Safety Reporting System [47]
	References
14: Current Trends in Risk Management and Patient Safety
	14.1	 Concepts and Principles
		14.1.1	 Just Culture (A Culture of Safety “from Justice”): The Search for Balance Between the Human Factor and the System
		14.1.2	 PROMs (Patient-Reported Outcome Measures): Listening to the Patient
		14.1.3	 Risk Management in Home Hospitalization
	14.2	 Patient Safety Practices: What Truly Reduces the Risks to Patient Safety?
	14.3	 Changes in Regulations as a Lever to Advance Patient Safety
	14.4	 Second and Third Victim: Consequences and Coping
	14.5	 Methodologies and Tools (See Also Chap. 11)
	14.6	 Ethics: Defining the Therapist’s Duties in the Context of Treatment Safety and Risk Management—Reporting and Transparency
	14.7	 Research Activity, Professional Journalism
	14.8	 Availability of Health Services, Queues, and Patient Flow Control [27–32]
	References
15: Patient Safety and Risk Management During the COVID-19 Pandemic: The Israeli Experience
	15.1	 The Beginning of the Pandemic and Initial Insights (Waves I and II)
		15.1.1	 Management Strategy
		15.1.2	 Infrastructure in the Hospitals
		15.1.3	 Repeated Comments that Appeared in the Survey
		15.1.4	 Training of the Teams
		15.1.5	 Clinical Activity Not Related to COVID-19
		15.1.6	 Attrition of Staff Members
		15.1.7	 Family Visits and Patient Experience
		15.1.8	 Human Resources
		15.1.9	 Protection and Infection
		15.1.10 Diagnosis, Case Management, Treatment, and Resuscitation
			15.1.10.1	 Diagnosis of COVID-19 Patients
			15.1.10.2	 Treatment of COVID-19 Patients
			15.1.10.3	 Giving Oxygen and Respiration
	15.2	 Breakdown of Wave Times and Variants [1, 2]
	15.3	 Convalescence, Discharge, Transfer, and Therapeutic Sequence
	15.4	 Main Recommendations in the Field of Management Strategy
	15.5	 Recommendations Regarding Staff Protection and Infection
	15.6	 Recommendations Regarding Diagnosis, Case Management, Treatment, and Ventilation
	15.7	 Recommendations Regarding the Sequence of Treatment and Recovery
	15.8	 Recruiting Researchers to Eradicate the Pandemic
		15.8.1	 Two International Bodies Have Established Noteworthy Research Programs
	15.9	 Learning While Treating and Applying the Initial Insights
	15.10	 Decrease in Clinical Activity While Maintaining Performance Quality
	15.11	 Quality and Patient Safety During the COVID-19 Pandemic
		15.11.1 Types of Activity
		15.11.2 Examples of These Activities During the COVID-19 Pandemic Include the Following
		15.11.3 What Is the Right Thing to Do and How Should Risk Managers Be Integrated into Crisis Efforts and Contribute Their Skills to the Management of Future Crises?
	15.12	 Activities of the Patient Safety and Risk Management Team During the Pandemic
		15.12.1 Respiratory Alerts in the COVID-19 Wards
		15.12.2 Monitoring the Screens and Cameras in Control Rooms in COVID-19 Wards
		15.12.3 Fire Safety in COVID-19 Wards
			15.12.3.1	 The Decisions Reached During This Discussion Were as Follows
	15.13	 Risk Management in COVID-19 Vaccination
		15.13.1 The Working Method for the Administration of Vaccinations Is as Follows
		15.13.2 Follow-Up After Side Effects and Unusual Events After the Vaccine Injection
	15.14	 Conclusions of the Committee Assigned to Check the Quality of Hospitalization of COVID-19 Patients in General Hospitals, Including the Third Wave of the Pandemic
	15.15	 Summary of Hospitalization of COVID-19 Patients in General Hospitals and Comparison of Mortality Among Waves I–III [19, 20]
		15.15.1 Cohort Results
	15.16	 Long-Term COVID-19
	References