Part I. IN THE BEGINNING
1. The Hidden Epidemic The Harvard Medical Practice Study
2. It's Not Bad People Error in Medicine
3. Changing the System The Adverse Drug Events Study
4. Coming Together The Annenberg Conference
5. A Home of Our Own The National Patient Safety Foundation
Part II. INSTITUTIONAL RESPONSES
6. We Can Do This The Institute for Healthcare Improvement Adverse Drug Events Collaborative
7. Who Will Lead? The Executive Session
8. A Community of Concern The Massachusetts Coalition for the Prevention of Medical Errors
9. When the IOM Speaks IOM Quality of Care Committee and Report
10. The Government Responds The Agency for Healthcare Research and Quality
11. Setting Standards The National Quality Forum
12. Enforcing Standards The Joint Commission
13. Partners in Progress Patient Safety in the United Kingdom
14. Going Global The World Health Organization
15. Just Do It The Surgical Checklist
16. Spreading the Word The Salzburg Seminar
17. Publish or Perish British Medical Journal Theme issue, New England Journal of Medicine Series
Part III. GETTING TO WORK Key issues and how they were dealt with
18. Sleepy Doctors Work hours and the Accreditation Council for Graduate Medical Education
19. A Conspiracy of Silence Disclosure, Apology, and Restitution
20. Who Can I Trust? Ensuring physician competence
21. Everyone Counts Building a culture of respect
Part IV. CREATING A CULTURE OF SAFETY
22. Make No Little Plans The Lucian Leape Institute
23. Now the Hard Part Creating a culture of safety
This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement's founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today's modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US.
Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve.
Captivatingly written with an "insider's" tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.
Lucian L. Leape, MD
Immediate Past Chair, Lucian Leape Institute for Healthcare Improvement
Adjunct Professor of Health Policy
Harvard T.H. Chan School of Public Health
Lucian Leape, MD is a physician and professor at Harvard School of Public Health, who has been active in trying to improve the medical system to reduce medical error. In 1994 he had an article, "Error in Medicine," published in JAMA. In 1997, he testified before a subcommittee of the US Senate with his recommendations for improving medical safety.
Leape is known as the father of the patient safety movement has spent the last 30 years of his working life campaigning for change in the American healthcare system. He travels the world to give talks and lectures, influencing many of the world's brightest medics.
Leape is the Chair of the Lucian Leape Institute at the National Patient Safety Foundation. The Institute, founded in 2007, is charged with defining strategic paths and calls to action for the field of patient safety, offering vision and context for the many efforts underway within health care, and providing the leverage necessary for change at the system level. Its members comprise national thought leaders with a common interest in patient safety whose expertise and influence are brought to bear as the Institute calls for the innovation necessary to expedite the work and create ignificant, sustainable improvements in culture, process, and outcomes critical to safer health care.