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... radiation, calculating the radiation dose, delivering the treatment, and following quality assurance processes to ensure correct delivery. ... Just as home computers regularly undergo upgrades of operating systems (for example, Windows XP to Windows 7) and ... Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: ... Int J Radiat Oncol Biol Phys 42:651a659, Oct. 1, 1998. of care devised and authorized by WHQ8 (see wide.
|Title||:||The Value of Close Calls in Improving Patient Safety|
|Author||:||Albert W. Wu, Joint Commission Resources, Inc|
|Publisher||:||Joint Commission Resources - 2011-01-01|