Part I. Introduction.- 1. Guidelines and Safety Practices for Improving Patient Safety.- 2. Brief story of a clinical risk manager.- 3. Human Error and Patient Safety.- 4. Looking forward to the future.- 5. Safer care: shaping the future.- 6. Patients for Patient Safety.- 7. Human Factors and Ergonomics in Health Care and Patient Safety from the Perspective of Medical Residents.- Part II. Background.- 8. Patient Safety in the World.- 9. Infection Prevention and Control.- 10. The patient journey.- 11. Adverse event investigation and risk assessment.- 12. From theory to real world integration: implementation science and beyond.- Part III. Patient safety in the main clinical specialties.- 13. Intensive care and anesthesiology.- 14. "Safe Surgery Saves Lives" .- 15. Emergency Department Clinical Risk.- 16. Obstetric Safety Patient.- 17. Patient Safety in the main clinical specialties.- 18. Risks in Oncology and Radiation Therapy.- 19. Orthopaedics and Traumatology.- 20.Patient Safety & Risk Management in Mental Health.- 21. Pediatrics.- 22. Patient safety in the main clinical specialties: Radiology.- 23. Organ Donor Risk Stratification in Italy.- 24. Patient Safety in Laboratory Medicine.- 25. Ophthalmology.- Part IV Healthcare organization.- 26. Community and Primary Care.- 27. Complexity science as a frame for understanding the management and delivery of high quality and safer care.- 28. Measuring clinical workflow to improve quality and safety.- 29. Shiftwork Organization.- 30. Non Technical Skills in Healthcare.- 31. Medication safety.- 32. Digital technology and usabililty and ergonomics of medical devices.- 33. Lessons learned from the Japan Obstetric Compensation System for Cerebral Palsy: A novel system of data aggregation, investigation, amelioration, and no-fault compensation.- 34. Coping with the COVID -19 pandemic: roles and responsibilities for preparedness.
Implementing safety practices in healthcare saves lives and improves the quality of care: it is therefore vital to apply good clinical practices, such as the WHO surgical checklist, to adopt the most appropriate measures for the prevention of assistance-related risks, and to identify the potential ones using tools such as reporting & learning systems.
The culture of safety in the care environment and of human factors influencing it should be developed from the beginning of medical studies and in the first years of professional practice, in order to have the maximum impact on clinicians' and nurses' behavior. Medical errors tend to vary with the level of proficiency and experience, and this must be taken into account in adverse events prevention. Human factors assume a decisive importance in resilient organizations, and an understanding of risk control and containment is fundamental for all medical and surgical specialties.
This open access book offers recommendations and examples of how to improve patient safety by changing practices, introducing organizational and technological innovations, and creating effective, patient-centered, timely, efficient, and equitable care systems, in order to spread the quality and patient safety culture among the new generation of healthcare professionals, and is intended for residents and young professionals in different clinical specialties.
Liam Donaldson is an honorary graduate of the University of Leicester and was formerly a lecturer at the university's Department of Community Health before becoming a Senior Lecturer in Epidemiology in 1981, when he also gained his MD. He served as the Chief Medical Officer of the Health Protection Agency (UK) and has been the chairman of the National Patient Safety Agency. He trained as a surgeon and went on to take up teaching and research posts at the University of Leicester. He is Chancellor of Newcastle University and Professor of Health Policy at Imperial College, London. He is a member of the International Advisory Council at APCO Worldwide Inc. and has received the Picker Institute Award for Excellence and the World Health Executive Forum Distinguished Leader Award.
Walter Ricciardi is a Professor of Hygiene and Public Health at the Catholic University of the Sacred Heart in Rome and is past president of the European Public Health Association (EUPHA) and of the of the Italian National Institute of Health. He was a member of the Ministry of Health's Higher Health Council and the Italian Minister of Health appointed him chair of the Public Health Section of the Council. He was appointed member of the Expert Panel on Effective Ways of Investing in Health (European Commission, DG - SANTE) and member of the Steering Committee of the Center for Global Health Research and Studies at the Medical School, Catholic University of the Sacred Heart. He was appointed director of the WHO Collaborating Centre for Health Policy, Governance and Leadership at the Institute of Public Health at the same university.
Sue Sheridan was the director of Patient Engagement for the Patient-Centered Outcomes Research Institute (PCORI). Before that she was the external lead of the Patients for Patient Safety program at the World Health Organization (WHO). Sheridan is a co-founder and past president of Parents of Infants and Children with Kernicterus (brain damage from jaundice), and was involved in implementing a new standard of care in jaundice management. She is also a co-founder of Consumers Advancing Patient Safety.
Riccardo Tartaglia, MD, specialized in occupational medicine, hygiene and public health and is certified as an ergonomist by Centre for Registration European Ergonomist. He is currently a partner & healthcare manager of the research and design studio "BSD - By Strategic Design" and an affiliate professional at the Institute of Management at the School of Advanced Studies Sant'Anna - Pisa, where, for more than ten years he has also been the scientific coordinator of the advanced course in Clinical Risk Management. He is president of the Italian Network for Safety in Health Care. Since 2003 he has been director of the Centre for Clinical Risk Management and Patient Safety - Tuscany Region (WHO CC) and he has been coordinator of the Patient Safety Committee of Italian Regions for ten years. He is currently a member of the National Observatory for Safety Practices (AGENAS). He was president of the Italian Ergonomics and Human Factors Society. In 2017 he was appointed ISQua Expert, and in 2018 he was made a fellow of the International Ergonomic Association.