Textbook of Patient Safety and Clinical Risk Management

Foreword
Preface
Acknowledgements
Contents
Part I: Introduction
	1: Guidelines and Safety Practices for Improving Patient Safety
		1.1	 Introduction
		1.2	 The Need to Understand Guidelines Before Improving Safety
		1.3	 The Current Patient Safety Picture and the Demand for Guidelines
		1.4	 Implementing the Research on Patient Safety to Improve Clinical Practice
		1.5	 Working Towards Producing Guidelines That Improve Safety Practices
		1.6	 The Challenges of Improving Safety and the Current Limits of Guidelines
		1.7	 Recommendations
		References
	2: Brief Story of a Clinical Risk Manager
		2.1	 Introduction
		2.2	 The Start
		2.3	 The Evolution of the Patient Safety System
		2.4	 The Network of Clinical Risk Manager
		2.5	 Training and Instruction
		2.6	 Adverse Events
		2.7	 The First Results
		2.8	 The Relationship with Politics and Managers
		2.9	 The Italian Law on the Safety of Care
		References
	3: Human Error and Patient Safety
		3.1	 Introduction
		3.2	 What Is an Error?
		3.3	 Understanding Error
			3.3.1	 Slips and Lapses
			3.3.2	 Mistakes
			3.3.3	 Violations
		3.4	 Understanding the Influence of the Wider System
		3.5	 Contributory Factors: Seven Levels of Safety
		3.6	 Putting It All Together: Illustration of Two Cases from an Acute Care Setting
			3.6.1	 Case 1: An Avoidable Patient Fall
			3.6.2	 Case 2: An Avoidable Emergency Laparotomy in a Case of Ectopic Pregnancy
		3.7	 Conducting Your Own Incident Investigation
		3.8	 Systems Analysis of Clinical Incidents
			3.8.1	 From Analysis to Meaningful Action
		3.9	 Supporting Patients, Families, and Staff
		3.10	 Conclusions and Recommendations
		References
	4: Looking to the Future
		4.1	 Introduction
		4.2	 The Vision for the Future
		4.3	 The Challenges to Overcome to Facilitate Safety
		4.4	 Develop the Language and Culture of Safety
		4.5	 Promote Psychological Safety
		4.6	 Design for Health and for Safety
		4.7	 Social Determinants of Patient Safety
		4.8	 Harnessing Technology for the Future (Reference Chap. 33)
		4.9	 Conclusion
		References
			Overview
			Develop the Language and Culture of Safety
			Psychological Safety and Well-Being
			Design for Safety
			Social Determinants for Patient Safety
			Digital Health and Patient Safety
	5: Safer Care: Shaping the Future
		5.1	 Introduction
		5.2	 Thinking About Safer Healthcare
			5.2.1	 Accidents and Incidents: The Importance of Systems
			5.2.2	 Culture, Blame, and Accountability
			5.2.3	 Leadership at the Frontline
		5.3	 Global Action to Improve Safety
			5.3.1	 Patient Safety on the Global Health Agenda
			5.3.2	 World Alliance for Patient Safety: Becoming Global
			5.3.3	 The Global Patient Safety Challenges
			5.3.4	 Patients and Families: Championing Change
			5.3.5	 African Partnerships for Patient Safety
			5.3.6	 Third Global Patient Safety Challenge: Medication Without Harm
			5.3.7	 The 2019 WHA Resolution and World Patient Safety Day
		5.4	 Conclusions
		References
	6: Patients for Patient Safety
		6.1	 Introduction
		6.2	 What is Co-production in Healthcare?
		6.3	 Background: The Genesis of a Global Movement for Co-production for Safer Care
		6.4	 Co-Production in Research
			6.4.1	 Example: United States
				6.4.1.1	 Mothers Donating Data: Going from Research to Policy to Practice
				6.4.1.2	 Civil Society: Driving Patient-Centered Research to Prevent Diagnostic Errors
		6.5	 Co-production in Medical Professions Education Courses
			6.5.1	 Example: Mexico
				6.5.1.1	 Leveraging a Regional Network of PFPS Champions to Enhance Medical Education
			6.5.2	 Example: Denmark
				6.5.2.1	 Patients as Educators
		6.6	 Co-production in Healthcare Organization Quality Improvement
			6.6.1	 Example: Egypt
				6.6.1.1	 Improving Disparities in Care for New Mothers: The Power of Partnership Between a Civil Society Leader and a Public Teaching Hospital
			6.6.2	 Italy
				6.6.2.1	 Democratizing Healthcare: A Government-Driven/Citizen Partnership to Improve Patient Centeredness
		6.7	 Co-Production in Policy
			6.7.1	 Example: Canada
				6.7.1.1	 Working from Within: Co-producing National Policy as an Insider
		6.8	 Conclusion
		References
	7: Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents
		7.1	 Introduction
		7.2	 Application of SEIPS Model to Medical Residents
		7.3	 Linkage of Work System to Patient Safety and Medical Resident Well-Being
		7.4	 Challenges and Trade-Offs in Improving Residents’ Work System
		7.5	 Role of Residents in Improving Their Work System
		7.6	 Conclusion
		References
Part II: Background
	8: Patient Safety in the World
		8.1	 Introduction
		8.2	 Epidemiology of Adverse Events
		8.3	 Most Frequent Adverse Events
			8.3.1	 Medication Errors
			8.3.2	 Healthcare-Associated Infections
			8.3.3	 Unsafe Surgical Procedures
			8.3.4	 Unsafe Injections
			8.3.5	 Diagnostic Errors
			8.3.6	 Venous Thromboembolism
			8.3.7	 Radiation Errors
			8.3.8	 Unsafe Transfusion
		8.4	 Implementation Strategy
		8.5	 Recommendations and Future Challenges
		Bibliography
	9: Infection Prevention and Control
		9.1	 Introduction
		9.2	 Main Healthcare-Associated Infection
			9.2.1	 Urinary Tract Infections (UTIs)
			9.2.2	 Bloodstream Infections (BSIs)
			9.2.3	 Surgical Site Infections
			9.2.4	 Healthcare-Associated Pneumonia
		9.3	 Antimicrobial Resistance
		9.4	 Healthcare-Associated Infection Prevention
			9.4.1	 The Prevention and Control of Healthcare-Associated Infection: A Challenge for Clinical Risk Management
			9.4.2	 Risk Management Tools
				9.4.2.1	 Root Cause Analysis
				9.4.2.2	 Significant Event Audit
				9.4.2.3	 Process Analysis
				9.4.2.4	 Failure Modes and Effects Analysis
			9.4.3	 The Best Practices Approach
				9.4.3.1	 Hand Hygiene
				9.4.3.2	 Antimicrobial Stewardship
				9.4.3.3	 Care Bundles
					CAUTI Maintenance Bundle
					Ventilator Bundle
		9.5	 Engaging Patients and Families in Infection Prevention
		9.6	 Identification and Rapid Management of Sepsis: A Test Bed for the Integration of Risk Management and IPC
			9.6.1	 Sepsis and Septic Shock Today
			9.6.2	 Sepsis as an Adverse Event: Failures in Identification and Management
		9.7	 Conclusions
		References
	10: The Patient Journey
		10.1	 Introduction
		10.2	 The Patient Journey
		10.3	 Contextualizing Patient Safety in the Patient Journey
		10.4	 From PartecipaSalute to the Accademia del Cittadino: The Importance of Training Courses to Empower Patients
		10.5	 Recommendations
		References
	11: Adverse Event Investigation and Risk Assessment
		11.1	 Risk Management in Complex Human Systems and Organizations
			11.1.1	 Living with Uncertainty
			11.1.2	 Two Levels of Risk Management in Healthcare Systems
		11.2	 Patient Safety Management
		11.3	 Clinical Risk Management
		11.4	 Systemic Analysis of Adverse Events
			11.4.1	 The Dynamics of an Incident
			11.4.2	 A Practical Approach: The London Protocol Revisited
		11.5	 Analysis of Systems and Processes Reliability
		11.6	 An Integrated Vision of Patient Safety
		References
	12: From Theory to Real-World Integration: Implementation Science and Beyond
		12.1	 Introduction
			12.1.1	 Characteristics of Healthcare and Its Complexity
			12.1.2	 Epidemiology of Adverse Events and Medical Errors
				12.1.2.1	 Barriers to Safe Practice in Healthcare Settings
			12.1.3	 Error and Barriers to Safety: The Human or the System?
		12.2	 Approaches to Ensuring Quality and Safety
			12.2.1	 The Role of Implementation Science and Ethnography in the Implementation of Patient Safety Initiatives
				12.2.1.1	 WHO Twinning Partnership for Improvement (TPI) Model
				12.2.1.2	 Institute for Healthcare Improvement Breakthrough Collaborative
				12.2.1.3	 Case Study: Kenya
			12.2.2	 Challenges and Lessons Learned from the Field Experience and the Need for More Extensive Collaboration and Integration of Different Approaches
			12.2.3	 Human Factors and Ergonomics
		12.3	 Way Forward
			12.3.1	 International Ergonomics Association General Framework Model
		References
Part III: Patient Safety in the Main Clinical Specialties
	13: Intensive Care and Anesthesiology
		13.1	 Introduction
		13.2	 Epidemiology of Adverse Events
		13.3	 Most Frequent Errors
		13.4	 Safety Practices and Implementation Strategies
			13.4.1	 Medication Errors
			13.4.2	 Monitoring
			13.4.3	 Equipment
			13.4.4	 Cognitive Aids
			13.4.5	 Communication and Teamwork
			13.4.6	 Building a Safety Culture
			13.4.7	 Psychological Status of Staff and Staffing Policies
			13.4.8	 The Building Factor
		13.5	 Recommendations
		References
	14: Safe Surgery Saves Lives
		14.1	 Safety Best Practices in Surgery
		14.2	 Factors Which Influence Patient Safety in Surgery
		14.3	 Techniques and Procedures
		14.4	 Surgical Equipment and Instruments
		14.5	 Pathways and Practice Management Guidelines
		14.6	 Gender
		14.7	 Training
		14.8	 Costs and Risks
		14.9	 Infection Control
		14.10	 Surgical Safety Checklist
		14.11	 Overlap Between Surgical and Other Safety Initiatives
		14.12	 Technical and Non-technical Skills
		14.13	 Simulation
		14.14	 Training Future Leaders in Patient Safety
		14.15	 Clinical Cases
			14.15.1 “I was rather sure that they were here!!!” The Case of the Missing Forceps
				14.15.1.1	 Case Analysis According to Risk Management Approach
			14.15.2 “I used to move my left arm before surgery” A Case of Patient Positioning on the Operating Table
				14.15.2.1	 Case Analysis According to Risk Management Approach
			14.15.3 “My clinic note said to remove the left lung nodule” A Case of Wrong Site Surgery
		Bibliography
	15: Emergency Department Clinical Risk
		15.1	 Background of Emergency Departments
		15.2	 Epidemiology of Adverse Events in Emergency Department
		15.3	 Most Frequent Errors Depends on: Patient, Provider, and System
		15.4	 Safety Practices and Implementation Strategy
			15.4.1	 Infrastructure Requirement
			15.4.2	 Basic Clinical Management Process and Protocols for Quality Emergency Care
			15.4.3	 Establishing a Unit Quality Department
			15.4.4	 Measuring Quality of Performance (Quality Indicators)
			15.4.5	 Sharing Best Practices
			15.4.6	 Adapting to Changing Realities
				15.4.6.1	 Digitization
				15.4.6.2	 Measuring Patient Feedback
					Service Excellency
					Clinical Audit
				15.4.6.3	 Test Optimization
				15.4.6.4	 Work Culture
					Safety
					Reference to Standards
					Communication Best Practice
					Culture of Safety
					Standardize
					Regulation
					Financial Incentive
					Liability Reform
		15.5	 Clinical Cases About Worse Practices That Didn’t Consider the Importance of Non-Technical Skills/Technical Skills
			15.5.1	 Non-Technical Skills Case
			15.5.2	 Technical Skills: Central Venous Line
		15.6	 Recommendation
		References
	16: Obstetric Safety Patient
		16.1	 Introduction
		16.2	 Patient Safety
		16.3	 Most Frequent Errors and Adverse Events
		16.4	 Recommendation
		References
	17: Patient Safety in Internal Medicine
		17.1	 Epidemiology of Adverse Events
		17.2	 Most Common Errors
			17.2.1	 Patient Identification Errors
			17.2.2	 Clinical Reasoning Errors
			17.2.3	 Medication Errors
				17.2.3.1	 Special Focus: Oxygen and Noninvasive Ventilation
			17.2.4	 Interventional Procedure-Related Errors
			17.2.5	 Communication Errors
				17.2.5.1	 Handoff
				17.2.5.2	 Ward Round
				17.2.5.3	 Clinical Records
		17.3	 Safety Practices and Implementation Strategy
			17.3.1	 Prevention of Age and Frailty-Related Adverse Events
			17.3.2	 Prevention of Healthcare-Associated Infections
			17.3.3	 Prevention of Venous Thromboembolism
			17.3.4	 Prevention of Pressure Ulcers
			17.3.5	 Clinical Monitoring by Early Warning Scores
			17.3.6	 Sepsis Bundles
			17.3.7	 Safe Management of Outlier Patients
		17.4	 Case Studies
			17.4.1	 Case Study 1
			17.4.2	 Case Study 2
			17.4.3	 Epicrisis and Recommendations
				17.4.3.1	 Clinical Case 1
				17.4.3.2	 Clinical Case 2
		References
	18: Risks in Oncology and Radiation Therapy
		18.1	 Introduction
		18.2	 The Epidemiological Context
		18.3	 Epidemiology of Adverse Effects
		18.4	 Medication Errors in Oncology Practice
		18.5	 Safety Practices and Implementation Strategy in Clinical Oncology
		18.6	 Radiotherapy
		18.7	 Safety Practices and Implementation Strategy for Radiotherapy
		18.8	 Volumes–Outcomes Relationship in Surgery
		18.9	 Case History
		18.10	 Final Recommendations
		References
	19: Patient Safety in Orthopedics and Traumatology
		19.1	 Introduction
		19.2	 Epidemiology of Adverse Advent
		19.3	 Most Frequent Errors
		19.4	 Safety Practices and Implementation Strategy
		19.5	 Clinical Cases
			19.5.1	 Case 1
			19.5.2	 Case 2
		19.6	 Recommendations
		References
	20: Patient Safety and Risk Management in Mental Health
		20.1	 Introduction
		20.2	 Epidemiology of Adverse Events in Patients Receiving Mental Healthcare
			20.2.1	 Nondrug-Related Adverse Events
				20.2.1.1	 Falls
				20.2.1.2	 Assault
				20.2.1.3	 Sexual Contact
				20.2.1.4	 Self-Harm
				20.2.1.5	 Other Nondrug Adverse Events
			20.2.2	 Drug Adverse Events
		20.3	 Medical Errors in Psychiatric Care
			20.3.1	 Common Errors and Dangerous Outcomes
				20.3.1.1	 Medication Errors
				20.3.1.2	 Restraint and Seclusion
				20.3.1.3	 Suicide
			20.3.2	 Nondrug Medical Error
				20.3.2.1	 Errors Contributing to Elopement
				20.3.2.2	 Errors Contributing to Contraband
				20.3.2.3	 Other Errors
		20.4	 Safety Practices and Implementation Strategies
			20.4.1	 Role of the Hospital Environment in Patient Safety
			20.4.2	 Role of Organizational Management in Patient Safety
			20.4.3	 Role of Staff in Patient Safety
			20.4.4	 Role of the Patient in Patient Safety Practices
		20.5	 Conclusion
		20.6	 Case Studies
			20.6.1	 Case Example 1
				20.6.1.1	 Discussion
			20.6.2	 Case Example 2
				20.6.2.1	 Discussion
		References
	21: Patient Safety in Pediatrics
		21.1	 Epidemiology of Adverse Events in Pediatrics: Some Numbers and Some Reflections
		21.2	 The Importance of Understanding the Context for Patient Safety Practices for Pediatrics
			21.2.1	 Simulation as a Key Factor for Implementation of Solutions for Safety in Pediatrics
			21.2.2	 Clinical Case: Safe Care in Pediatric Emergency
				21.2.2.1	 9.15 pm
				21.2.2.2	 9.18 pm
				21.2.2.3	 9.20 pm
				21.2.2.4	 9.24 pm
				21.2.2.5	 9.27 pm
				21.2.2.6	 9.32 pm
				21.2.2.7	 9:34 pm
				21.2.2.8	 Final Considerations
		References
	22: Patient Safety in Radiology
		22.1	 Introduction
		22.2	 Radiation Protection
		22.3	 Magnetic Resonance Imaging (MRI) Hazards
			22.3.1	 Static Magnetic Fields (SMF)
			22.3.2	 Gradient Magnetic Fields (GMF)
			22.3.3	 Radiofrequency (RF) Magnetic Field
			22.3.4	 Implants and Devices
		22.4	 Contrast Agent-Related Risks
			22.4.1	 Patient Selection
			22.4.2	 Identify the Risk Factors and Contraindications
			22.4.3	 Safe Injection of Contrast Agents
			22.4.4	 Allergy-Like and Chemotoxic Reactions
			22.4.5	 Adverse Events Related to Iodinated Contrast Agents
			22.4.6	 Adverse Events Related to Gadolinium-Based Contrast Agents (GBCA)
		22.5	 Conclusion
		References
	23: Organ Donor Risk Stratification in Italy
		23.1	 Background
			23.1.1	 The Donor Risk
			23.1.2	 The Principles of Donor Risk Evaluation
			23.1.3	 The Risk Evaluation Process
				23.1.3.1	 Organ Procurement
				23.1.3.2	 Posttransplant Course
			23.1.4	 The Donor Risk Categories
		23.2	 Discussion
		References
	24: Patient Safety in Laboratory Medicine
		24.1	 Epidemiology of Adverse Events
			24.1.1	 Laboratory Medicine as a Driver in Ensuring Patient Safety
			24.1.2	 From Laboratory-Related Errors to Diagnostic Errors
		24.2	 Safety Practices and Implementation Strategy
			24.2.1	 ISO 15189 Accreditation
			24.2.2	 Quality Indicators
			24.2.3	 Professional Competence: Education and Skill
			24.2.4	 Risk Management Procedures
		24.3	 Clinical Cases
		24.4	 Recommendations
		References
	25: Patient Safety in Ophthalmology
		25.1	 Introduction
		25.2	 Epidemiology of Adverse Events: Safety Practices and Implementation Strategy
			25.2.1	 Cataract Surgery
				25.2.1.1	 Intraoperative Adverse Events
				25.2.1.2	 Postoperative Adverse Events
				25.2.1.3	 Safety Practices and Implementation Strategy in Cataract Surgery
					A. Preoperative Care
						Patient Assessment
						Supplemental Evaluation
						Risk Stratification
					B. Perioperative Care
						Patient Alimentation and Therapy
						Prophylaxis of Infections and Sterility
					C. Postoperative Care
					D. Training
			25.2.2	 Intravitreal Injection Therapy
				25.2.2.1 Adverse Events, Safety Practices, and Implementation Strategy
		25.3	 Most Frequent Errors: Safety Practices and Implementation Strategy
			25.3.1	 The Most Common Medical Errors and Preventive Strategies in Ophthalmology
				25.3.1.1	 Wrong-Site Eye Surgery
					Introduction
					Causes and Risk Factors
					Preventive Strategies
						A. The Universal Protocol
						B. Consent Form
				25.3.1.2	 Cataract Surgery-Related Errors
					Introduction
					Causes and Risk Factors
					Preventive Strategies
				25.3.1.3	 Intravitreal Therapy-Related Errors
					Introduction
					Preventive Strategies
				25.3.1.4	 Medication-Related Errors in Ophthalmology
					Introduction
					Causes and Risk Factors
					Preventive Strategies
		25.4	 Clinical Case
			25.4.1	 Clinical Case Recommendations
		25.5	 Recommendations
		25.6	 Conclusion
		References
Part IV: Healthcare Organization
	26: Community and Primary Care
		26.1	 Epidemiology of Adverse Event
		26.2	 Most Frequent Errors
			26.2.1	 Preclinical Errors
			26.2.2	 Clinical Errors
		26.3	 Clinical Cases
			26.3.1	 Clinical Case: Being Alert
			26.3.2	 Clinical Case: A Foreseeable Error
		26.4	 Safety Procedures
			26.4.1	 Diagnosis
			26.4.2	 Prescribing
			26.4.3	 Communication
			26.4.4	 Organizational Change
		26.5	 Recommendations
		References
	27: Complexity Science as a Frame for Understanding the Management and Delivery of High Quality and Safer Care
		27.1	 The Complexities of Healthcare
		27.2	 Managing Complexity
		27.3	 Responding to Complexity
		27.4	 Researching Quality and Safety Using Complexity Thinking
		27.5	 Real World Examples
			27.5.1	 The Lynch Syndrome Study
			27.5.2	 Research on Medical Emergency Teams
			27.5.3	 Social Networks in a Ward and an Emergency Department
			27.5.4	 Australian Genomics as a Learning Community
			27.5.5	 The Deepening Our Understanding of Quality in Australia Studies
		27.6	 Extending These Ideas and Studies to the Future Organisation of Quality and Safety
		27.7	 Where to From Here?
		27.8	 Recommendations
		References
	28: Measuring Clinical Workflow to Improve Quality and Safety
		28.1	 What Is Clinical Workflow?
		28.2	 Studying Clinical Workflow
			28.2.1	 Approaches for Studying Clinical Workflows
			28.2.2	 Time and Motion Studies
			28.2.3	 What Types of Questions Can Clinical Workflow Studies Answer?
			28.2.4	 Interruptions
			28.2.5	 Multitasking
		28.3	 Cultural and Organisational Considerations in Conducting Clinical Workflow Studies
		28.4	 Data Quality, Analysis and Interpretation in Clinical Workflow Studies
			28.4.1	 Important Practical Considerations with Ensuring Data Quality in Workflow Studies
			28.4.2	 Analysis
			28.4.3	 Inter-observer Reliability
			28.4.4	 Disseminating Findings to Influence Practice and Policy
		28.5	 Conclusion
		References
	29: Shiftwork Organization
		29.1	 Introduction to Shift Work
			29.1.1	 Definition and Main Features
			29.1.2	 Chronobiological Aspects
		29.2	 Effects of Shift Work on Worker Health and Impact on Patient Safety
			29.2.1	 Sleep Deprivation and Vigilance
			29.2.2	 Interference in Performance Efficiency and Patient Safety
			29.2.3	 Health Disorders
		29.3	 Preventive Actions and Recommendations
			29.3.1	 Ergonomic Criteria for the Organization of Shift Schedules
			29.3.2	 Other Organizational Aspects
		29.4	 Some Considerations for Resident Doctors
		References
	30: Non-technical Skills in Healthcare
		30.1	 Introduction
			30.1.1 Practical Overview of NTS Training Topics in Healthcare
		30.2	 Performance Shaping Factors
		30.3	 Planning and Preparation Skills
		30.4	 Situation Awareness and Perception of Risk
			30.4.1 ‘Perception of Risk’
		30.5	 Expert Decision-Making
			30.5.1 Metacognition
			30.5.2 Affect
			30.5.3 Communication and Decision-Making
			30.5.4 Stress and Decision-Making
		30.6	 Communication
			30.6.1 Specific/Directed/Acknowledged Communication
			30.6.2 Briefings and Handovers
			30.6.3 SBAR
			30.6.4 Escalation of Concern: Graded Assertiveness
		30.7	 Teamwork and Leadership Skills
			30.7.1 The ‘Anatomy’ of Teams
			30.7.2 Unidisciplinary Teams
			30.7.3 Multidisciplinary Teams
			30.7.4 Committees
			30.7.5 Improving Team Performance
			30.7.6 Calling for Help Early: Team Assembly
			30.7.7 Team Structure: Clear Leader, Roles and Goals
			30.7.8 Team-Oriented Communication
			30.7.9 Decision-Making
			30.7.10 Managing Workload and Time
			30.7.11 Team Situation Awareness
			30.7.12 Team Familiarity, Group Climate and Interpersonal Conflict
			30.7.13 Debriefing
			30.7.14 Leadership, Command and Control
			30.7.15 Leadership Styles and Situational Leadership
			30.7.16 Transferable Command and Control
		30.8	 Teaching Non-technical Skills
		30.9	 Summary
		References
	31: Medication Safety
		31.1	 Introduction
			31.1.1	 A Focus on Transitions of Care, Polypharmacy and High-Risk Situations
			31.1.2	 Learning Objectives
			31.1.3	 Learning Outcomes: Knowledge and Performance
				31.1.3.1	 Knowledge Requirements
				31.1.3.2	 Performance Requirements
		31.2	 Medication Safety in Transitions of Care
			31.2.1	 Prevalence of Medication Discrepancies
			31.2.2	 Medication-Related Harm During Transitions of Care
			31.2.3	 Making Medication Use Safer During Transitions of Care
				31.2.3.1	 Medication Reconciliation
				31.2.3.2	 Information Clarity and Availability at All Transition of Care Points
					Appropriate Tools and Technology
					Electronic Health Records (EHRs)
					Information to Support Safe Use of Medications
				31.2.3.3	 Patient Engagement and Education
				31.2.3.4	 Monitoring and Measurement
		31.3	 Medication Safety in Polypharmacy
			31.3.1	 Prevalence of Polypharmacy
			31.3.2	 Medication-Related Harm in Polypharmacy
			31.3.3	 Approaches for Addressing Polypharmacy
				31.3.3.1	 Measuring Appropriateness of Medications
				31.3.3.2	 Medication Reviews
				31.3.3.3	 Rational Prescribing
				31.3.3.4	 Deprescribing
				31.3.3.5	 Health System Changes
				31.3.3.6	 Practical Tips
				31.3.3.7	 Practicing Patient-Centred Care
		31.4	 High-Risk Situations in Medication Safety
			31.4.1	 Medication Errors and Related Harm in High-Risk Situations
				31.4.1.1	 High-Risk Medications
				31.4.1.2	 High-Risk Patients
				31.4.1.3	 High-Risk Contexts
			31.4.2	 Some Ways to Ensure Medication Safety in High-Risk Situations
				31.4.2.1	 High-Risk Medications
				31.4.2.2	 High-Risk Patients
				31.4.2.3	 High-Risk Contexts
		31.5	 Final Recommendations and Conclusions
		References
	32: Digital Technology and Usability and Ergonomics of Medical Devices
		32.1	 Introduction
		32.2	 Some Studies on Medical Devices
		32.3	 Beneficiaries of Usable Medical Devices
		32.4	 Usability Evaluation
			32.4.1	 Methods for Usability Assessment
			32.4.2	 The Usability Assessments in Reality
		32.5	 Conclusion
		References
	33: Lessons Learned from the Japan Obstetric Compensation System for Cerebral Palsy: A Novel System of Data Aggregation, Investigation, Amelioration, and No-Fault Compensation
		33.1	 Context for the Introduction of the JOCS-CP: Increasing Conflict Over Cerebral Palsy and Hopes for a No-Fault Compensation System
		33.2	 The Meaning of “No-Fault Compensation” in the JOCS-CP
		33.3	 Compensation Driven by the Indemnity Insurance Mechanism
		33.4	 Monetary Compensation
		33.5	 Epidemiology of Adverse Events
		33.6	 Investigation: Identifying Error During Delivery
		33.7	 Controversy on Disclosing Preventability in Individual Cases
			33.7.1 Guidance for “The Items to Consider for Better Obstetrical/Perinatal Care” Section of the Investigative Report
			33.7.2 Guidance for Handling Questions from Guardians/Families During the Investigative Process
		33.8	 Survey on the Investigative Report
		33.9	 Most Frequent Errors
		33.10	 Safety Practices and Implementation Strategy
		33.11	 Two Clinical Cases
			33.11.1 Case 1
				33.11.1.1	 Clinical Course
				33.11.1.2	 Probable Cause of Cerebral Palsy
				33.11.1.3	 Evaluation of Procedures
				33.11.1.4	 Recommendations
			33.11.2 Case 2
				33.11.2.1	 Clinical Course
				33.11.2.2	 Probable Cause of Cerebral Palsy
				33.11.2.3	 Evaluation of Procedures
				33.11.2.4	 Recommendations
		33.12	 Recommendations
			33.12.1 Vacuum Delivery
			33.12.2 Administration of Uterine Contracting Agents
			33.12.3 Fetal Heart Rate Monitoring
			33.12.4 Care for Placental Abruption
		Further Readings
	34: Coping with the COVID-19 Pandemic: Roles and Responsibilities for Preparedness
		34.1	 Introduction
		34.2	 COVID-19 Summary
		34.3	 Magnitude of COVID-19
		34.4	 Fundamental Aspects of the WHO Pandemic Plan
			34.4.1	 Phases
			34.4.2	 Framework
			34.4.3	 Overarching Goals
			34.4.4	 Key Actions
		34.5	 Criticalities in the Application of the WHO Pandemic Approach During the COVID-19 Outbreak
			34.5.1	 Planning and Coordination
			34.5.2	 Situation Monitoring and Assessment
			34.5.3	 Prevention and Containment
			34.5.4	 Healthcare System Response
			34.5.5	 Communication
				34.5.5.1	 Make the Message Clear
				34.5.5.2	 Keep the Message Consistent
				34.5.5.3	 Timeliness
				34.5.5.4	 Monitor Social Media
				34.5.5.5	 Select the Most Appropriate Method of Communication
		34.6	 Improvement Actions Based on Lessons Learned
			34.6.1	 General Guidelines
			34.6.2	 Guidelines for Obstetrics and Pediatrics
			34.6.3	 Guidelines for Caring for Immunocompromised Patients
			34.6.4	 Guidelines for Special Contexts
			34.6.5	 Guidelines for General Practitioners
			34.6.6	 Guidelines for Long-Term Care Facilities
			34.6.7	 Guidelines for Hemodialysis Patients
		34.7	 Conclusions
		References