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First, Do Less Harm

First, Do Less Harm: Confronting the Inconvenient Problems of Patient Safety

Ross Koppel
Suzanne Gordon
Copyright Date: 2012
Edition: 1
Published by: Cornell University Press,
Pages: 280
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  • Book Info
    First, Do Less Harm
    Book Description:

    Each year, hospital-acquired infections, prescribing and treatment errors, lost documents and test reports, communication failures, and other problems have caused thousands of deaths in the United States, added millions of days to patients' hospital stays, and cost Americans tens of billions of dollars. Despite (and sometimes because of) new medical information technology and numerous well-intentioned initiatives to address these problems, threats to patient safety remain, and in some areas are on the rise.

    In First, Do Less Harm, twelve health care professionals and researchers plus two former patients look at patient safety from a variety of perspectives, finding many of the proposed solutions to be inadequate or impractical. Several contributors to this book attribute the failure to confront patient safety concerns to the influence of the "market model" on medicine and emphasize the need for hospital-wide teamwork and greater involvement from frontline workers (from janitors and aides to nurses and physicians) in planning, implementing, and evaluating effective safety initiatives.

    Several chapters in First, Do Less Harm focus on the critical role of interprofessional and occupational practice in patient safety. Rather than focusing on the usual suspects-physicians, safety champions, or high level management-these chapters expand the list of "stakeholders" and patient safety advocates to include nurses, patient care assistants, and other staff, as well as the health care unions that may represent them. First, Do Less Harm also highlights workplace issues that negatively affect safety: including sleeplessness, excessive workloads, outsourcing of hospital cleaning, and lack of teamwork between physicians and other health care staff. In two chapters, experts explain why the promise of health care information technology to fix safety problems remains unrealized, with examples that are at once humorous and frightening. A book that will be required reading for physicians, nurses, hospital administrators, public health officers, quality and risk managers, healthcare educators, economists, and policymakers, First, Do Less Harm concludes with a list of twenty-seven paradoxes and challenges facing everyone interested in making care safe for both patients and those who care for them.

    eISBN: 978-0-8014-6407-2
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-x)
  3. Introduction
    (pp. 1-8)
    Suzanne Gordon and Ross Koppel

    A few years ago my wife, Meg, had major surgery at a highly regarded, fully wired hospital. After surgery, Meg was wheeled up to the floor with her assigned room. Computer displays at the nurses’ station indicated she had left the post-anesthesia care unit and was now on her floor. I was in the lobby waiting to be told of her room assignment. After about forty-five minutes I became alarmed. I searched the probable hospital floors and found Meg shivering, dehydrated, and alone by the elevators. I ran to the nurses’ station down the hallway and asked why she’d been...

  4. Chapter 1 The Data Model That Nearly Killed Me
    (pp. 9-20)
    Joseph M. Bugajski

    In 2009 the U.S. government appropriated about $38 billion for health information technology and to create a program to digitize and network health information.¹ The appropriation law also defines rules for some health information standards and systems. It does not, however, explain how to test the validity of the information used by those systems. I argue that these prescriptions for a Nationwide Health Information Network (NHIN), though necessary, are insufficient.

    During the last week of January 2009, a faulty electronic networked health information system nearly killed me despite its being run by two advanced, state-of-the-art medical facilities. This will come...

  5. Chapter 2 Too Mean to Clean: How We Forgot to Clean Our Hospitals
    (pp. 21-40)
    Rosalind Stanwell-Smith

    In April 2010, the centenary of the death of Florence Nightingale, a nurse came before the British Nursing and Midwifery Council for having told an elderly bedridden patient to clean up his urine spillage. Handing him a mop and bucket, she reportedly said, “Here you go, you can mop it up.” Finding her guilty of misconduct, the council nevertheless ruled that her fitness to practice at a major London teaching hospital was not impaired. The media were quick to connect this story to deaths in another English hospital associated with tales of dirty wards and soiled sheets going unchanged and...

  6. Chapter 3 What Goes without Saying in Patient Safety
    (pp. 41-61)
    Suzanne Gordon and Bonnie O’Connor

    Since its inception, the patient safety movement in the United States has focused on easily quantifiable indicators whose incidence can readily be compared over time and among venues. Consistently missing from the general discourse and implementation planning is any systematic study or integration of a wide range of sociocultural and organizational issues that largely defy quantification and that can significantly affect efforts to protect patients. Included among these are intraprofessional and interprofessional hierarchies and turf battles; interprofessional antipathies, competition, and fundamental misconceptions; linguistic incompatibilities and other interprofessional communications barriers; and poor (if any) conflict management.

    Exploring each of these critical...

  7. Chapter 4 Health Care Information Technology to the Rescue
    (pp. 62-89)
    Ross Koppel, Stephen M. Davidson, Robert L. Wears and Christine A. Sinsky

    It’s late in the nightshift. A new doctor uses the hospital’s computerized physician (or provider) order entry system (CPOE) to choose the appropriate dose for a medication she has prescribed only occasionally. In her hospital, as in many others in the United States, this CPOE has been installed, at great expense, to improve patient safety and prevent medication errors. She finds the medication on the screen. The doses are displayed in a stack from top to bottom: 5 mg, 4 mg, 1 mg, 3 mg, 2 mg. She assumes the display reflects dose preferences, indicates common doses, or obeys some...

  8. Chapter 5 A Day in the Life of a Nurse
    (pp. 90-92)
    Kathleen Burke

    As a condition of participation in Medicare, the Centers for Medicare and Medicaid Services (CMS) in its Conditions of Participation Interpretive Guidelines, has made a requirement that scheduled medications be administered within thirty minutes before or after the specified time. To the outside observer, this rule seems quite a reasonable expectation—that a patient would receive a medication close to the time that it was scheduled or ordered. But from the perspective of a bedside nurse, this rule seems to have been devised by people who have little experience with the way nursing work is organized and who have had...

  9. Chapter 6 Excluded Actors in Patient Safety
    (pp. 93-122)
    Peter Lazes, Suzanne Gordon and Sameh Samy

    Diane Sommers is an ICU (intensive care unit) nurse at a major East Coast teaching hospital.¹ Over the past few years her hospital has launched a number of pioneering safety initiatives: operating room and ICU checklists, efforts to reduce falls and infections, as well as safety meetings on individual patient care units. On the unit, a specific time is set aside each week so that staff can meet and learn about new safety methods, as well as discuss their concerns and insights. For Sommers, this has been a promising development. The problem, however, is that she and her colleagues have...

  10. Chapter 7 Nursing as Patient Safety Net: Systems Issues and Future Directions
    (pp. 123-149)
    Sean Clarke

    In most industrialized countries, nurses are the largest group of health care providers working directly with patients. They are responsible for implementing much hands-on patient care, particularly in acute care hospitals, monitoring patients for complications of illnesses and untoward reactions to treatment as well as protecting them from the “hazards” of medical care.¹

    Recent years have been marked by unprecedented attention to patient safety and quality of care issues and the introduction of many programs and initiatives intended to reduce hazards and improve consistency of services in health care institutions around the world. In their frontline roles in clinical practice,...

  11. Chapter 8 Physicians, Sleep Deprivation, and Safety
    (pp. 150-167)
    Christopher P. Landrigan

    In the mid-1990s, when I was an intern in pediatrics, here is what one of my typical days “on call” looked like. I dragged myself out of bed at about 5:30 AM (an hour and a half later than my friends who went into surgical residencies, but similar to most other interns), showered, threw on some scrubs, and ran out the door. After grabbing a cup of coffee and a doughnut, I hopped on the T—the public transportation system in Boston—and headed in to work. Arriving at about 6:30, I scurried around to the rooms of the four...

  12. Chapter 9 Sleep-deprived Nurses: Sleep and Schedule Challenges in Nursing
    (pp. 168-179)
    Alison M. Trinkoff and Jeanne Geiger-Brown

    U.S. hospitals and patients are increasingly relying on nurses who are working rotating shifts that, in many cases, involve longer and longer hours. Current work patterns can and do adversely affect sleep. In turn, inadequate sleep increases the risk that nurses may make more errors and sustain more injuries. When nurses do not sleep enough for several days each week over the course of several years, they also increase their risks for obesity or diabetes and cardiovascular diseases along with other health problems. Sleep deprivation also negatively affects their interpersonal interactions with patients and colleagues, as well as with family...

  13. Chapter 10 Wounds That Don’t Heal: Nurses’ Experience with Medication Errors
    (pp. 180-195)
    Linda A. Treiber and Jackie H. Jones

    Medical errors have been the topic of much research, much publication, and much public concern.¹ Because nurses administer the vast majority of medications, they inevitably make the majority of these administration mistakes. Yet there is little understanding of the complex occupational and personal trauma suffered by the practitioner who makes an error if that person is a nurse.

    We know from studies of physicians that new doctors are supposed to “forgive and remember” their mistakes, provided they learn how to avoid them in the future.² But unlike physicians, who have formalized this practice, nurses have no such process. Nurses tend...

  14. Chapter 11 On Teams, Teamwork, and Team Intelligence
    (pp. 196-220)
    Suzanne Gordon

    The mystery that motivates this book is why more than a decade’s worth of time, energy, and resources devoted to patient safety have not produced as much progress as many anticipated. Other chapters have discussed a number of factors that negatively impact patient safety. This chapter looks at how the failure to construct a robust concept of teams, teamwork, and team intelligence contributes to the slow pace of patient safety improvement. To explore teamwork and team intelligence, in the following pages I first examine inter- and intraprofessional hierarchies and rivalries, then show how professional self-definitions prevent cooperation and coordination, before...

  15. Conclusion: Twenty-seven Paradoxes, Ironies, and Challenges of Patient Safety
    (pp. 221-246)
    Ross Koppel, Suzanne Gordon and Joel Leon Telles

    Patient safety efforts are paradoxical. Their successes are usually ephemeral and frequently challenging. Patient safety is an action, not an achieved status. It’s the avoidance of errors and creation of routines to maximize safe actions; it’s stocking the right items in the right bins. Achieving safe care for patients demands specific actions and constant vigilance both at a worm’s-eye view and at a bird’s-eye view. Yet despite the sometimes elusive, sometimes clear, and sometimes protean requirements, the consequences of failing to ensure patients’ safety are real, costly, and often horrible.

    Patient safety is both the absence of harm to patients...

  16. Notes
    (pp. 247-276)
  17. Contributors
    (pp. 277-282)
  18. Index
    (pp. 283-290)