Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed â€" a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.

Near Miss Reporting as a Safety Tool arises from a meeting of safety professionals, academicians, and consultants from Western-Europe and Canada held in Eindhoven, the Netherlands, in September 1989. The book deals with near-miss reporting in various systems, mostly in the context of errors and accidents. The book begins by discussing the effects of bad management decisions in the design phase and a framework that will describe or manage these near misses through reporting, description, analysis, interpretation, and suggestions. Seven modules that compose this framework, called the Near Miss Management System (NMMS), along with pertinent cases, are explained. The book notes that near misses are ignored because of technical myopia, action-oriented organizations, event-focused organizations, consequence driven, and variables in quality of reporting. The organizational and management aspects of the NMMS are then analyzed within the commonly accepted culture and experience of the company. The book also presents comparative application of near miss information systems covering a wide range of industrial and transport environment. Such presentation allows differences and similarities to come into view more easily. The text will prove valuable for safety professionals in the nuclear and chemical industry and in road, railway, and air traffic management. Professors and students in safety management will likewise appreciate this book.

An incredible 30,000 flights – at least – arrive safely at their destinations every day. But a handful don’t, while some come terrifyingly close to crashing. When even the smallest thing does go wrong at 35,000 feet, the result is nearly always a fast-unfolding tragedy. This extensive collection of compelling real-life accounts of air disasters and near-disasters provides a sobering, alternative history of the just over 105 years that passengers have been travelling by air, from the very earliest fatality to recent calamities. But there are incredible stories of heroism against the odds, too, such as that of Captain Chesley Sullenberger who successfully landed his aircraft with both engines gone on the Hudson River in New York, saving the lives of everyone aboard, and of the American Airlines crew who prevented terrorist Richard Reid from exploding a bomb hidden in his shoe three months after 9/11. The book also details the often ingenious, always painstaking work done by air-accident investigators, while a glossary helps to clarify the occasional, inevitable bits of jargon.

Close calls, narrow escapes, or near hits. History has shown repeatedly that these "near-miss" incidents often precede loss producing events, but are largely ignored or go unreported because nothing (no injury, damage or loss) happened. Thus, many opportunities to prevent the accidents that the organization has not yet had are lost. Recognizing and

All anesthesiologists eventually face the fear of a “near miss,” when a patient’s life has been put at risk. Learning from the experience is crucial to professionalism and the ongoing development of expertise. Drawing on forty-plus years of practice in major metropolitan hospitals in the United States, Norway, and South Africa, John Brock-Utne, MD presents 80 carefully selected cases that provide the basis for lessons and tips to prevent potential disaster. The cases emphasize problem-centered learning and span a broad range of topics—from an outbreak of operating room infection (could it be the anesthesia equipment?), complications of fiberoptic intubations, and problems with epidural drug pumps, to performing an urgent tracheostomy for the first time, working with an aggressive surgeon, and what to do when a patient falls off the operating table during surgery. 80 true-story clinical “near misses” never before published, ideal for problem-centered learning, recommendations, references, and discussions accompany most cases, rich basis for teaching discussions both in or out of the operating room, settings include sophisticated as well as rudimentary anesthetic environments, complements the author’s other case book, Clinical Anesthesia: Near Misses and Lessons Learned (Springer, 2008).

The book begins in a small town setting where aviation has earned a bad name because of an avoidable fatal crash. It is autobiographical only in the sense of the author's progression from non-interest to intense involvement in all aspects of flying. The title "Near Misses" describes close calls as well as choices that determined final outcomes. The highlights of an aspiring Naval Aviator's struggle to become a fighter pilot are revealed. Along the way, bits of historical and technical information are included The main theme is that anyone attempting the same task could benefit by either avoiding the pitfalls described or by being prepared to compensate for them in ways similar to those of the author.

This book outlines the many anesthesia-related obstacles, concerns, and challenges that may be encountered by western trained anesthesiologist in low-resourced settings. Each chapter presents a challenging scenario with solutions. It is therefore an essential handbook that will prepare those performing anesthesia in this milieu. All case studies represent real accounts discussing equipment and drug constraints as well as the ethical questions that arise for western doctors working in this environment. Socially conscious and timely, Anesthesia in Low-Resourced Settings is an invaluable resource for medical practitioners who plan to work in these challenging settings.

Because close calls, often termed near misses, don't raise the same concerns about malpractice liability and may be less emotionally charged than errors that cause serious harm, they are a unique source of learning for individuals and organizations striving to keep patients safe. This book tells how to take advantage of these lessons to prevent today's close call from turning into tomorrow's catastrophic event. Special Features: * Foreword by human error expert James Reason, Ph.D. * Authoritative tutorials on what the literature tells us about the concept of close calls and their identification, relationship with errors, and use in assessing and improving the safety and reliability of health care. * 15 detailed case studies from a variety of clinical disciplines and specialties to show how health care organizations use close calls to identify and solve patient safety problems

The Oscar-shortlisted documentary Command and Control, directed by Robert Kenner, finds its origins in Eric Schlosser's book and continues to explore the little-known history of the management and safety concerns of America's nuclear aresenal. “A devastatingly lucid and detailed new history of nuclear weapons in the U.S. Fascinating.” —Lev Grossman, TIME Magazine “Perilous and gripping . . . Schlosser skillfully weaves together an engrossing account of both the science and the politics of nuclear weapons safety.” —San Francisco Chronicle A myth-shattering exposé of America’s nuclear weapons Famed investigative journalist Eric Schlosser digs deep to uncover secrets about the management of America’s nuclear arsenal. A groundbreaking account of accidents, near misses, extraordinary heroism, and technological breakthroughs, Command and Control explores the dilemma that has existed since the dawn of the nuclear age: How do you deploy weapons of mass destruction without being destroyed by them? That question has never been resolved—and Schlosser reveals how the combination of human fallibility and technological complexity still poses a grave risk to mankind. While the harms of global warming increasingly dominate the news, the equally dangerous yet more immediate threat of nuclear weapons has been largely forgotten. Written with the vibrancy of a first-rate thriller, Command and Control interweaves the minute-by-minute story of an accident at a nuclear missile silo in rural Arkansas with a historical narrative that spans more than fifty years. It depicts the urgent effort by American scientists, policy makers, and military officers to ensure that nuclear weapons can’t be stolen, sabotaged, used without permission, or detonated inadvertently. Schlosser also looks at the Cold War from a new perspective, offering history from the ground up, telling the stories of bomber pilots, missile commanders, maintenance crews, and other ordinary servicemen who risked their lives to avert a nuclear holocaust. At the heart of the book lies the struggle, amid the rolling hills and small farms of Damascus, Arkansas, to prevent the explosion of a ballistic missile carrying the most powerful nuclear warhead ever built by the United States. Drawing on recently declassified documents and interviews with people who designed and routinely handled nuclear weapons, Command and Control takes readers into a terrifying but fascinating world that, until now, has been largely hidden from view. Through the details of a single accident, Schlosser illustrates how an unlikely event can become unavoidable, how small risks can have terrible consequences, and how the most brilliant minds in the nation can only provide us with an illusion of control. Audacious, gripping, and unforgettable, Command and Control is a tour de force of investigative journalism, an eye-opening look at the dangers of America’s nuclear age.