Veterinary Patient Safety 1st Edition

Cover
Table of Contents
Title Page
Copyright Page
Dedication Page
Preface
Introduction
1 The Language of (Patient) Safety
What is the Difference Between an Adverse Event and a Patient Safety Incident?
Acronyms and Abbreviations
References
2 A Brief History of Healthcare‐associated Harm and Patient Safety
A Timeline of Patient Safety in Healthcare Literature
References
3 Modern Prevalence and Impact of Healthcare‐Associated Harm
Overall Prevalence of Harm
Prevalence and Type of Healthcare‐associated Harm by Medical Setting and Clinical Specialty
How Does this Harm Break Down?
What is the Evidence for Veterinary Healthcare‐associated Harm?
Conclusion
References
4 Why are Patients Harmed by Healthcare? Theories, Concepts and Models
From Simple Linear Causality Models to Complex Non‐linear Models
More Advanced Models
Current Approaches to Safety
Ways of Envisioning and Understanding Working Practices
Summary
References
5 Human Performance and Error
What is an Error?
Classification of Human Error
How We Make Decisions
The Effect of the Social Environment
Other Important Facets of Human Nature
When Might Human Error be the Most Influential Factor in an Accident?
Conclusion
References
6 Organisational, Professional and Safety Cultures
What Do the Terms Organisational, Professional and Safety Culture Mean?
What is Safety Culture?
Other Key Principles Pertaining to Safety Culture
Assessing Safety Culture
Errors Made When Applying Information Gained from Safety Culture Surveys
The Link Between Safety Culture and Outcomes
Conclusion
References
7 Dealing with the Non‐clinical Aftermath of an Incident or Error
Primary Victims
Disclosure of Errors
Barriers to Disclosure
Considerations for Disclosing Error
Communication Models for Error Disclosure
Communication Models in Veterinary Healthcare
Disclosure and Organisational Culture
Managing Secondary Victims
Highlight the Volatility, Uncertainty, Complexity and Ambiguity of Clinical Work
Conclusions
References
8 Methods of Assessment and Measurement in Patient Safety
Underlying Principles
Summary
Surveys and Questionnaires
Modified Delphi Method
Chart Review
General Considerations for Performing Chart Reviews
Surveillance of Adverse Events and Incidents
Safety Diaries
Surveillance Forms
Non‐routine Event Surveillance
Incident Reporting
What Should a Good Incident Report Consist of?
Benefits and Limitations of Incident Reporting
How to Improve the Quantity and Quality of Incident Reports
Examples of Established Reporting Systems
Examples of Reporting Systems in Veterinary Healthcare
Generating Your Own Reporting System
Getting the Most Out of a Reporting System
Conclusions on Incident Reporting Systems
Debriefing
The Structure of Debriefs
Debrief Tools and Frameworks
Benefits and Limitations of Debriefing
Debriefing in Healthcare
Debriefing in Veterinary Healthcare
Cognitive Autopsy
Interview Techniques
The Aim of Interviews in Patient Safety
Unstructured and Semi‐structured Interviews
Designing, Planning and Preparing for Interviews
Critical Incident Technique
Focus Groups
Setting Up a Focus Group
Benefits and Limitations of Focus Groups
Focus Groups in Veterinary Healthcare
Morbidity and Mortality Rounds
Case Selection
Timing, Frequency and Duration
Moderator
Presenter
Audience
Tone and Environment
Format
Morbidity and Mortality Rounds in Healthcare
Morbidity and Mortality Rounds in Veterinary Healthcare
Direct Observation
The Direct Observation Process
The Observer
Other Considerations
Benefits and Limitations of Direct Observation
Closed Malpractice and Liability Insurance Claims
What is Included in a Closed Claim Investigation
Benefits and Limitations of Closed Claim Studies
Closed Claim Analysis in Healthcare
Closed Claim Analysis in Veterinary Healthcare
Big Data, Large Databases and Registries
Benefits and Limitations of Big Data and Registries
Outcome Registries in Healthcare
Benefits and Limitations to Investigations Using Big Data and Large Databases
Process Walks and Process Mapping
Define the Process and Its Boundaries
Purpose and Outcomes
Resources Involved in Process
Define Current Ideal Standards
Establish How the Process Fits Within the System
Data Collection
Investigative Questions
Developing the Process Map
Analysis of Process Maps
Benefits and Limitations of Process Mapping
Process Mapping in Human Healthcare
Process Mapping in Veterinary Healthcare
Using Multiple Methods to Collect Patient Safety Data
Benefits and Limitations of Using Multiple Methods
Use of Multiple Methods in Veterinary Patient Safety Investigations
References
9 Analysis Techniques for Patient Safety Investigations
Quantitative versus Qualitative Analysis
Setting Basic Objectives for Analysis
Setting Improvement Objectives: SMART Goals
Which Incidents or Situations Should I Analyse?
Process Analysis
General Approaches to Safety Investigations
Conclusion
Timeline Techniques
Event and Condition Network Analysis
Root Cause Analysis
The Five Whys Technique
Ishikawa or Fishbone Diagram
Bow‐Tie Diagrams
The London Protocol Systems‐Based Approach
Systems Engineering Initiative for Patient Safety
Human Factors Analysis Classification System
Further Incident Analysis Techniques
Failure Modes and Effects Analysis
The Structured What‐If Technique
Functional Resonance Analysis Method
Qualitative Techniques: Thematic Analysis
References
10 Patient Safety Interventions
Interventions Categorised According to Human Factors Engineering
Recognising the ‘Need for Change’
Conclusions
Individual‐based Strategies
Non‐Technical Skills Development
Team‐based Strategies
System‐level Strategies
References
11 Feedback and Closing the Loop
Clinical Audit
Conclusions
References
12 Ethics in Patient Safety Investigations
Do We Need to Consider Ethics When We are Just Trying to do What is Best for Our Patients?
What is the Difference Between Patient Safety Activities and Research?
Why is this a Problem?
Why is There so Much Confusion?
How Can We Differentiate Between a Quality Improvement Activity and Research?
When does a Patient Safety Activity Require Ethical Review?
Why is this Distinction so Important?
Why Can Traditional Ethical Review of Patient Safety Activities be Problematic?
Guidelines on the Performance of Quality Improvement Activities
What are the Key Ethical Considerations in Patient Safety Activities?
When Should the Investigators Intervene?
Informed Consent
What Ethical Considerations Should be Made When Designing a Patient Safety Activity?
Conclusion
References
13 Suggested Unified Approach for Veterinary Healthcare
Building the Prototype ‘A PET Hospital’ Model
Brief Walkthrough of the Completed A VET Hospital Model
Applying the A VET Hospital Model to a Patient Safety Investigation
Conclusion
References
Appendix A: Glossary of Terms
Appendix B: List of Veterinary Clinical Practice Guidelines
Anaesthesia and Analgesia
Emergency and Critical Care (including transfusion medicine)
Cardiology
Dentistry
Dermatology
Internal Medicine
Neurology
Oncology
General Practice
Equine
Appendix C: Case Studies
Index
End User License Agreement