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This book presents a systematic human factors-based proactive approach to the improvement of health care work and patient safety. The proposed approach delineates a more direct and powerful alternative to the contemporary dominant focus on error investigation and care providers' accountability. It demonstrates how significant improvements in the quality of care and enhancement of patient safety are contingent on a major shift from efforts and investments driven by a retroactive study of errors, incidents, and adverse events, to an emphasis on proactive human factors-driven intervention and the development of corresponding conceptual approaches and methods for its systematic implementation.
Yoel Donchin, Daniel Gopher
Human Factors and Safety in Medical Systems. On the History of Medical Errors. The Nature and Causes of Human Errors In Intensive Care Units. None Routine Human Factors and Team Work Events and Mishaps in Surgical Procedure. Errors in the Emergency Room. Intravenous Administration of Magnesium Sulfate. Human Factors in Neonatal Units. Design of an Information Display for an Emergency Ward. Design and Evaluation of a Medication Preparation Room. Design of Patient Medical Follow Up Record in Radiotherapy Treatment. Labeling of Infusion Lines and Drug Containers. The Emperor New Cloth - Design of Uniforms for the OR Team. Comparative Thinking and Inferences Formats of Physicians and Nurses. Briefing before Surgery. Breaks and Interference during Doctors Rounds. On the Distinction between Risk Management and Safety? The Conduct of Simulation and Replay of an Occurred Event. A Human Factors Focused Reporting System. Development of an Index of Safety Culture. Can Tired Intern Perform Safely. Gentle Enforcement of Care Safety Practices. Human Factors and Safety in Health Care Its Calls and Challenges. Physicians Epilogue.
