Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                

Patient Safety Handbook: Second Edition

Download as pdf or txt
Download as pdf or txt
You are on page 1of 30

Patient Safety

Handbook
Second Edition

Edited by
Barbara J. Youngberg, JD, MSW, BSN, FASHRM
Visiting Professor of Law
Academic Director, On-Line Legal Education
Loyola University Chicago
School of Law
Beazley Institute for Health Law and Policy
Chicago, IL

74042_CH00_FMXX_6181.indd 1 8/10/12 7:34 AM


World Headquarters
Jones & Bartlett Learning
5 Wall Street
Burlington, MA 01803
978-443-5000
info@jblearning.com
www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact
Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.

Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations,
professional associations, and other qualified organizations. For details and specific discount information, contact
the special sales department at Jones & Bartlett Learning via the above contact information or send an email to
specialsales@jblearning.com.

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system,
without written permission from the copyright owner.
Patient Safety Handbook, Second Edition is an independent publication and has not been authorized, sponsored, or
otherwise approved by the owners of the trademarks or service marks referenced in this product.
Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the
activities represented in the images.
This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered.
It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional
service. If legal advice or other expert assistance is required, the service of a competent professional person should be
sought.
Production Credits
Publisher: Michael Brown
Editorial Assistant: Chloe Falivene
Editorial Assistant: Kayla Dos Santos
Production Manager: Tracey McCrea
Senior Marketing Manager: Sophie Fleck Teague
Manufacturing and Inventory Control Supervisor: Amy Bacus
Composition: Publishers’ Design and Production Services, Inc.
Cover Design: Scott Moden
Cover Image: © Nagy Jozsef—Attila/ShutterStock, Inc.
Printing and Binding: Edwards Brothers Malloy
Cover Printing: Edwards Brothers Malloy
Library of Congress Cataloging-in-Publication Data
Patient safety handbook / edited by Barbara Youngberg. -- 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7637-7404-2 (pbk.)
I. Youngberg, Barbara J.
[DNLM: 1. Patient Safety. 2. Medical Errors--prevention & control. WX 185]
610--dc23
2012018525
6048
Printed in the United States of America
16 15 14 13 12 10 9 8 7 6 5 4 3 2 1

74042_CH00_FMXX_6181.indd 2 8/10/12 7:34 AM


To the mothers and fathers who have lost children due to medical
error, to the husbands and wives who have lost spouses, and to all
of those who have lost trust in our ability to recognize the privilege
of caring for you or those you love.

And to Anie, my daughter, who despite a challenging year,


taught me that hard work, focus, humor, and love is really what
makes for a good and meaningful life.

74042_CH00_FMXX_6181.indd 3 8/10/12 7:34 AM


74042_CH00_FMXX_6181.indd 4 8/10/12 7:34 AM
CONTENTS

Preface xxi
Foreword xxv
Helen Haskell
Contributors xxvii
Chapter 1 Understanding the First Institute of Medicine Report and Its Impact
on Patient Safety 1
Marsha Regenstein, PhD, MCP
Errors, Adverse Events, and Negligence: Some Common Terminology 2
Medical Errors and Patient Safety: What Does the Literature Show? 2
The Harvard Medical Practice Study 3
The Utah and Colorado Study 4
Other Selected Studies 4
To Err Is Human: The IOM Report and Recommendations 5
The Clinton Administration’s Response to the IOM Report 6
Legislative Proposals on Patient Safety 7
Current Reporting Requirements 7
State Requirements 7
Requirements of The Joint Commission 8
The Response from the American Hospital Association 9
Other Responses 9
Reasons for Optimism: Successful Strategies 10
Conclusion 12
Appendix: IOM Recommendations 12
References 15
Chapter 2 Patient Safety Movement: The Progress and the Work That Remains 17
Manisha Shaw, MBA, RCP and Karla M. Miller, PharmD, BCPP 17
Introduction 17
A History of Patient Safety 18
Creating a Culture of Safety 20
Most Common Patient Safety Concerns 21
Medication Errors 21
Hospital-Acquired Infections 22

74042_CH00_FMXX_6181.indd 5 8/10/12 7:34 AM


vi Contents

Surgical-Site Errors 22
Device Malfunctions 23
Error in Diagnosis 23
The Impact of Literacy on Patient Safety 23
Making Care Safer Through Research 24
Emerging Trends 24
Technology 24
Conclusions: Where We Stand Today 25
References 25
Chapter 3 Accelerating Patient Safety Improvement 29
Thomas R. Krause, PhD and John Hidley, MD 29
Introduction 29
Slow Progress 29
Getting in Gear 30
A Universal Metric for Patient Safety 31
Healthcare Worker Safety 34
A Healthcare Culture of Safety 35
Conclusion 36
References 36
Chapter 4 The Importance of Leadership to Advance Patient Safety 39
Barbara Balik, RN, EdD
Definition: Leaders 40
Definition: Healthcare Organization 40
How to Use the Content 40
Another Way 40
Board of Directors Leadership of Quality and Safety 41
Governance Role and Accountability for Safety 41
Assessment of Specific Behaviors to Govern for Safety 42
Questions Designed for Board Members to Understand the Safety
Strategy and Policy Implementation Within the Organization 42
Safety Science and Just Culture
Skills 43
Leadership Behaviors for Safety 44
Model for Leading and Sustaining Transformational Change 45
Personal Characteristics 45
A Single-Brain Organization 48
Knowledge to Lead Complex Organizations Plus Skills in the Science of
Safety, Just Culture, and Team Development 48
Assessment Tool—Individual Leaders or Teams 54
References 54
Additional Resources 55
Chapter 5 An Organization Development Framework For Transformational Change in
Patient Safety: A Guide For Hospital Senior Leaders 57
Raj Behal, MD, MBA
Scenario 58
What Is Culture? 58
Revisiting the Scenario 59

74042_CH00_FMXX_6181.indd 6 8/10/12 7:34 AM


Contents vii

First-Order Versus Second-Order Change 59


Creating an Urgency for Change While Providing an Infrastructure for
Change to Take Hold 60
The Burke–Litwin Model of Organizational Performance and Change 61
Changing Behavior 65
Three-Stage Change Model 65
Summing Up 66
References 67
Chapter 6 The Role of the Board of Directors in Advancing Patient Safety 69
Sarah Mick, JD, LLM and Shawn Mathis, JD, LLM
The Impact of Sarbanes-Oxley Reforms on Hospital Governance and
Patient Safety 70
Sarbanes-Oxley and Its Legacy 72
How Governance Impacts Financial Performance and Ratings 74
Board Oversight of Quality and Patient Safety 75
The McNulty Memorandum 77
Creating Vigilance for Safety at the Board Level 78
IHI Governance Intervention: Getting Boards on Board 79
Additional Organizations That Affirm the Board’s Role in Patient Safety 80
Challenges Boards May Face 81
IHI Mentor Hospitals 81
Board Education: Providing Boards with the Tools They Need to Succeed 81
Content for Effective Board Meetings 81
Use of Patient Safety Dashboards 82
Dashboard 82
Conclusion 83
References 83
Chapter 7 Toward a Philosophy of Patient Safety: Expanding the Systems
Approach to Medical Error 87
David Resnick, JD, PhD
The Problem of Medical Error 87
From Systems to Philosophies 88
Philosophical Ideas and Assumptions and Medical Error 90
Idea 1: The Definition of Medical Error 90
Idea 2: The Priority of Patient Safety 92
Idea 3: The Acceptance of Error 94
Conclusion 96
References 97
Chapter 8 Mistaking Error 99
David D. Woods, PhD and Richard I. Cook, MD
Introduction 99
Summary of the New Look Research Findings 108
References 109
Chapter 9 The Investigation and Analysis of Clinical Incidents 111
Charles Vincent, MD and David Hewett, MD
Research Foundations 112

74042_CH00_FMXX_6181.indd 7 8/10/12 7:34 AM


viii Contents

Reason’s Organizational Accident Model 113


A Framework for the Analysis of Risk and Safety in Medicine 113
Definitions and Essential Concepts 114
The Incident 114
Care Management Problems 114
Clinical Context and Patient Factors 114
Specific Contributory Factors 114
General Contributory Factors 114
The Investigation Process 115
Reviewing the Case Records 115
Framing the Problem 115
Undertaking the Interviews 115
Analysis of the Case 116
Preparation of the Report 117
Case Examples 117
Attempted Suicide in an Inpatient Psychiatric Unit 117
Implementation of the Protocol in a British Hospital 119
Discussion 121
Acknowledgments and Further Information 122
References 122
Chapter 10 Applying Epidemiology to Patient Safety 125
Mark Keroack, MD, MPH and Emily Rhinehart, RN, MPH, CIC, CPHQ
Epidemiology Versus Case-Based Analysis: The Forest and the Trees 126
Surveillance Systems Past and Present 127
Developing Surveillance Systems for Errors and Adverse Events 128
Assessing the Population at Risk 129
Selecting the Processes and Outcomes for Surveillance 129
Developing Definitions 130
Developing Data Collection Methods and Tools 131
Calculating Rates and Analyzing Data 133
Applying Risk Stratification and Subgroup Analysis 134
Reporting Results and Using the Data for the Development of Risk
Reduction Strategies 135
Concerns Regarding an Epidemiologic Approach to Patient Safety 136
Summary and Conclusions 140
References 141
Chapter 11 Patient Safety is an Organizational Systems Issue: Lessons From a
Variety of Industries 143
Karlene H. Roberts, PhD, Kuo Yu, and Daved van Stralen, MD
Foundations of Research That Can Inform Safety Issues 144
High-Reliability Organizations Research 145
Findings from HRO Research 145
Departure from Safety 146
A Safe Landing 147
A Broader Story 151
An Application in the Health Industry 151

74042_CH00_FMXX_6181.indd 8 8/10/12 7:34 AM


Contents ix

Conclusions 153
References 154
Chapter 12 Admitting Imperfection: Revelations From the Cockpit for the
World of Medicine 157
John J. Nance, JD
The Myth of Medical Infallibility 159
Aviation as a Cautionary Example for Health Care 161
Similarities between Aviation and Health Care 162
The Safety Hazards of the Isolated Omnipotent Leader:
Firing Captain Kirk 163
How Aviation Addressed Teamwork Problems 166
The Picard Method 167
Conclusion 168
Chapter 13 Creating a Just Culture: A Nonpunitive Approach to Medical Errors 169
Laura Ashpole, JD
Introduction 169
What Is a Just Culture? 170
Evaluating and Responding to Medical Errors 171
Building the Foundation for the Introduction of Just Culture Principles 171
One Organization’s Approach to Establishment of a Just Culture 172
The Dana-Farber Cancer Institute’s “Principles of a Fair and Just Culture” 173
A Statewide Effort to Implement the Just Culture Model 175
The Tools Necessary for Effectuation of a Just Culture 176
Conclusion 178
References 178
Chapter 14 Addressing Clinician Performance Problems as a Systems Issue 179
John A. Fromson, MD
References 184
Chapter 15 Improving Health Literacy to Advance Patient Safety 185
Caroline Chapman, JD 185
Introduction 185
Health Literacy Definition 186
Health Literacy and Patient Safety 187
Health Literacy Data 188
Safe Care for Non-English Speakers 190
Interpreters 191
Translation 191
Cultural Competency 192
The Law and Health Literacy 193
Informed Consent 193
Advanced Directives 194
Accreditation 194
Health Literacy Principles and Programs 194
Health Literacy Programs 195

74042_CH00_FMXX_6181.indd 9 8/10/12 7:34 AM


x Contents

Health Literacy Case Study 196


Health Literacy Tests 197
Conclusion 197
References 198
Chapter 16 The Leadership Role of the Chief Operating Officer in Aligning
Strategy and Operations to Create Patient Safety 201
Julianne M. Morath, RN, MS
A Call to Action 202
Declare Patient Safety Urgent and a Priority 203
Patient Safety Dialogues 203
Focus Groups 203
Naming Safety as a Priority 204
Accept Executive Responsibility 204
Leadership Exemplar: The Alcoa Story 205
High Reliability 205
Import and Apply New Knowledge and Skills 207
Process Auditing 207
Reward Systems 207
Pursual of Safety Standards 207
Perception of Risk 207
Command and Control 208
Apply New Tools and Build Infrastructure 208
Knowledge Base 208
Rapid-Cycle Change 209
Language 209
Process Auditing Tools and Methods 210
Architecture for Learning 210
Policies to Advance Partnerships with Patients and Their Families 210
Response to Medical Accidents 211
Measures 211
Assign Accountability 211
Mentoring an Accountability System 212
Engaging the Organization 212
Establish Blameless Reporting 212
Align External Controls 213
The Business Case 214
Summary 215
References 216
Chapter 17 The Role of the Risk Manager in Creating Patient Safety 217
Grena G. Porto, RN, MHA, ARM, CPHRM
What Is a High-Reliability Organization? 217
Auditing of Risk 218
Appropriate Reward System 220
System Quality Standards 221
Acknowledgment of Risk 222
Command and Control 223

74042_CH00_FMXX_6181.indd 10 8/10/12 7:34 AM


Contents xi

Conclusion 224
References 224
Chapter 18 Reducing Medical Errors: The Role of the Physician 225
Roy Magnusson, MD, MS, FACEP
The Changing Landscape 225
Central Role of the Physician 226
Selecting the Medical Staff 226
The Value of Peer Review and Ongoing Assessment of Clinical Performance 227
Collecting and Using Outcomes Data 227
Identifying and Assisting the Impaired Physician 227
Dealing with Disaster 228
Systems Redesign 229
Matching Resources to Needs: Physicians as Senior Administrators 230
Establishing Standards and Policy 230
Evidence-Based Medicine 231
Conclusion 231
References 232
Chapter 19 Engaging General Counsel in the Pursuit of Safety 233
Barbara J. Youngberg, JD, MSW, BSN, FASHRM
Protection of Medical Error Data 235
Peer Review Protection 236
The Value of Error Data to Plaintiff Attorneys 238
A Defense Attorney’s Strategy 239
References 241
Chapter 20 Growing Nursing Leadership in the Field of Patient Safety 243
Mary L. Salisbury, RN, MSN and Robert Simon, EdD, CPE
The Worst of Times 243
The Best of Times 244
Background: History and Duty of Nursing in Comprehensive Patient Safety 244
Characteristics of a Comprehensive Patient Safety Solution 245
The Form of Patient Safety is Embodied in Vision 246
The Function of Comprehensive Patient Safety is Embodied in Teamwork 247
Teamwork Case Study: MedTeams 248
History 248
Needs Assessment: Teamwork in Emergency Health Care 249
The MedTeams Teamwork Training System 249
Improving the Delivery of Emergency Care: MedTeams Validation 251
Leadership Considerations 251
Teamwork Summary 253
Conclusion 254
References 254
Chapter 21 Teamwork Communications and Training 257
Richard Lauve, MD
Definitions and Initial Thoughts 257
Reducing the Barriers to Collaboration 257

74042_CH00_FMXX_6181.indd 11 8/10/12 7:34 AM


xii Contents

The Need for a Team 257


Individual Domination 259
Resources 260
Training 261
Communications 262
Some Final Advice 263
Chapter 22 Teamwork: The Fundamental Building Block of High-Reliability
Organizations and Patient Safety 265
G. Eric Knox, MD and Kathleen Rice Simpson, PhD, RNC, FAAN
The Why, What, and Why Not of Teamwork 266
Why Teams Are Superior 266
What Is a Team? 266
Behaviors and Attributes of Effective Teams 267
Why Not Teams? Existing Barriers to Teamwork in the Healthcare
Environment 268
Aligning Operations to Build Team-Based High-Reliability Organizations:
Where to Start and How to Succeed 274
The Blunt End: Organizational Leadership Shapes the Clinical
Environment 274
The Sharp End: A Reflection of Blunt-End Organizational Priorities 277
Characteristics of Clinical Groups Operating Without Teamwork
or High Reliability (Those at High Risk for Medical Accidents) 278
Characteristics of and Strategies to Create High-Reliability Clinical
Units and Teamwork 279
When a Preventable Adverse Outcome Occurs in a High-Reliability
Clinical Unit 285
Conclusion 286
References 286
Chapter 23 Health Information Technology and Patient Safety 291
Laura B. Morgan, JD
Introduction 291
The Potential of HIT to Improve Patient Safety 291
Unintended Consequences of HIT on Patient Safety 292
Harnessing HIT’s Potential to Improve Patient Safety and Managing HIT’s
Unintended Consequences 295
Purchase the Safest Possible HIT Products 295
Develop HIT Systems That Align with the Provider’s Sociotechnical
Context 295
Optimize Patient Safety During the HIT Implementation Phase 296
Engage in Constant Improvement of HIT Practices 296
Conclusion 297
References 297
Chapter 24 Sleep Deprivation in Healthcare Professionals: The Effect on
Patient Safety 299
Mahendr S. Kochar, MD, MS, MBA, JD and Barbara A. Connelly, RN, MJ
Introduction 299

74042_CH00_FMXX_6181.indd 12 8/10/12 7:34 AM


Contents xiii

Understanding Sleep, Sleep Deprivation, and Fatigue 300


Circadian Rhythm and Sleep 301
Sleep Deprivation 301
Fatigue 302
The Effects of Healthcare Provider Sleep Deprivation and Fatigue on
Patient Safety 302
Current Status of Work-Hour Restrictions and the Potential for Change 304
Residents 304
2008 Recommendations of the Institute of Medicine on Duty Hours 304
ACGME Response to the 2008 IOM Report on Duty Hours 307
Nursing Profession’s Response to the 2004 IOM Report on Nursing
and Patient Safety 307
Solutions and Alternatives 307
Increasing Sleep Through Alternative Schedules 307
Improve Communication Techniques 308
Education and Research 309
Conclusion 310
References 310
Chapter 25 Supporting Healthcare Providers Impacted by Adverse Medical Events 313
Allison Caravana Lilly, MSW, LICSW, CEAP
Conducting an Assessment 315
Partners EAP’s Model for Response: Brigham and Women’s Hospital
Peer Support Team 316
Getting Buy In 316
Choosing Team Members 317
Peer Support Team Training 317
One-to-One Peer Support Training 317
Group Peer Support Training 318
Team Development 319
Marketing the Services 319
Lessons Learned 319
References 320
Acknowledgments 321
Chapter 26 Patient Handoffs—Perils and Opportunities 323
George R. Cybulski, MD, FACS
Introduction 323
Root Cause Analysis of Handoff Errors: Process of Handoffs 324
Root Cause Analysis of Handoff Errors: “Tribes” 326
Ways to Improve Handoffs 326
Standardizing Handoffs Using Techniques and Tools 327
Other Lessons from Industry 327
Surgeon Information Transfer and Communication (ITC) 327
Information Technology 328
Cross Talk Instead of Groupthink 328
Conclusion 329
References 330

74042_CH00_FMXX_6181.indd 13 8/10/12 7:34 AM


xiv Contents

Chapter 27 When Employees Are Safe, Patients Are Safer 333


Kathy Gerwig, MBA
Introduction 333
Health Care Is a Hazardous Occupation 333
Case Study: Creating Safe Environments at Kaiser Permanente 335
Workplace Safety Programs at Kaiser Permanente 337
Comprehensive Safety Management Program 337
Safe Patient Handling 338
Workplace Safety Leadership Walkarounds 338
Systems of Safety 339
Top 10 Evidence-Based Practices for Improving Injury Reduction
Performance 340
Workplace Safety Performance Measurement at Kaiser Permanente 342
Employee Perceptions 342
Lagging Indicators: Accepted Claims Injury Rate 343
Leading Indicators or Outcome Drivers 343
Establishing Benchmarks 343
Never Events 344
Performance Improvement 345
Digital Imaging 345
Conclusion 345
References 346
Chapter 28 Identifying and Addressing Physicians at High Risk for Medical
Malpractice Claims 347
Gerald B. Hickson, MD and James W. Pichert, PhD
Introduction 347
Why Patients File Suit 348
Malpractice Claims are Not Random 349
But Can’t You Do Something Constructive? 349
Supporting Infrastructure—An Office of Patient Relations 350
Initial Analysis of Patient Complaints 350
Self-Regulation and Professional Accountability 351
Changing Physician Practice Behaviors 353
The Vanderbilt Intervention Process 354
Intervention Skills Training 357
Results 358
Recruiting and Retaining Messengers 359
The Intervention Process 359
Intervention Results 360
National Standings 361
Claims Experience 362
Science and Local Politics 363
Communicating with Leaders 364
Sustaining Leadership Commitment and Support 365
Conclusion 366
References 366

74042_CH00_FMXX_6181.indd 14 8/10/12 7:34 AM


Contents xv

Chapter 29 Medical Malpractice Litigation: Conventional Wisdom Versus Reality 369


Marina Karp, MJ
The Campaign 370
Tort Reform as a National Policy Initiative 371
Conventional Wisdom 372
Reality of Malpractice Litigation 372
The Real Problem 373
Conclusion 377
References 377
Chapter 30 Quality and Safety Education for Nurses: Integrating Quality and Safety
Competencies into Nursing Education 381
Gwen Sherwood, PhD, RN, FAAN, Louise LaFramboise, PhD, RN,
Connie Miller, PhD, RN, and Bethany Robertson, DNP, CNM, NM
Quality and Safety Education for Nurses (QSEN) 382
Defining the Competencies 382
Patient-Centered Care 382
Interprofessional Teamwork and Collaboration 383
Evidence-Based Practice 383
Quality Improvement 383
Safety 384
Informatics 384
Defining the Gap between Nursing Curriculum and Goals for
Nursing Practice 385
Pilot School Learning Collaborative 385
Student Evaluation Survey 385
Delphi Survey 386
Pilot School Exemplars 386
Reaching a Tipping Point 390
References 391
Acknowledgment 392
Chapter 31 Supporting a Culture of Safety: The Magnet Recognition Program 393
Katherine A. Pischke-Winn, MBA, RN, Karen M. Stratton, PhD, RN, NE-BC,
Kathleen Ferket, RN, MSN, APN, and Wendy Tuzik Micek
Background 393
Introduction 394
Culture of Safety Definition 394
A Culture of Safety 394
Safety and Nurse Advocacy 396
The Magnet Recognition Program 398
Patient Safety and the Magnet Recognition Program Synergies 400
A Culture of Patient Safety and Magnet 401
Leadership and a Culture of Safety 404
Leadership Exemplars and Safety 404
Teamwork and a Culture of Safety 406

74042_CH00_FMXX_6181.indd 15 8/10/12 7:34 AM


xvi Contents

Teamwork Exemplars and Safety 407


Communication and a Culture of Patient Safety 408
Communication Exemplars and Safety 410
Evidence-Based Practice (EBP) and a Culture of Patient Safety 411
Evidence-Based Practice Exemplars and Safety 412
Learning and a Culture of Patient Safety 414
Learning Exemplars and Safety 415
Just Culture and Patient Safety 416
Just Culture Exemplar and Safety 417
Patient-Centered Care and a Culture of Safety 417
Patient-Centered Care Exemplars and Safety 419
Conclusion 420
References 421
Chapter 32 Teaching Physicians to Provide Safe Patient Care 425
Dennis O’Leary, MD and Lucian Leape, MD
Preface 425
Executive Summary 427
Introduction 427
Part I. The Need for Medical Education Reform 428
Square Pegs 428
Emerging Issues in Health Care 429
When Things Go Wrong 430
The Medical Education Culture 430
Selecting for What? 432
Core Competencies: The Missing Link 434
Educational Content and Methods Through a Different Prism 435
Part II. What Changes Are Needed 436
Creating the Right Culture 436
Part III. Strategies for Change 444
Accreditor Opportunities 444
Monitoring and Public
Reporting on Medical School Performance 446
Textbooks and Testing 448
Financial Incentives 448
Conclusion 450
References 451
Appendix Setting the Right Organization Context 455
Strategies for Teaching Patient Safety 456
Leveraging Change 456
Lucian Leape Institute at the National Patient Safety Foundation 457
National Patient Safety Foundation 457
Roundtable on Reforming Medical Education Invited Experts 457
Members of the Lucian Leape Institute at the National Patient Safety
Foundation 459
Reviewers 459
NPSF Staff 459

74042_CH00_FMXX_6181.indd 16 8/10/12 7:34 AM


Contents xvii

Chapter 33 Improving the Safety of the Medication Use Process 461


David A. Ehlert, PharmD and Steven S. Rough, MS
Background 462
Terminology 462
The Incidence of Medication Misadventures 463
Financial Impact 464
The Medication Use Process 464
Systems Approach 468
Medication Error Reporting 469
Technology 469
Desired Features for Reducing Errors 470
Decentralized Automated Dispensing Devices 471
Centralized Robotics for Dispensing Medications 472
Point-of-Care Bedside Medication Charting Systems and Bar Coding 474
Computerized Prescriber Order Entry 475
Medication Use Process Strategic Plan Within a Health System 476
Maximizing Medication Use Safety Within an Integrated Health System:
The University of Wisconsin Hospital and Clinics Model 478
Medication Safety Committee 479
UWHC Medication Error Reporting Process Task Force 480
Medication Ordering Performance Improvement Project 482
High-Alert Medication Policy 482
Recheck Campaign 484
Abbreviations 484
Medication Safety Week 486
UWHC Technology Model 486
Citywide and Statewide Approach 488
General Considerations for Health Systems 490
Conclusion 491
Acknowledgments 492
References 492
Chapter 34 Using Simulation to Advance Patient Safety 495
Keshia Carswell
Introduction 495
Background 495
Part Task Trainers 496
Standardized Patients or Actors 496
Screen-Based Computer Simulators 496
Complex Task Trainers 496
Mannequin Simulators 496
Hybrid Simulators 497
Simulation and Patient Safety 497
Nursing Education 497
Medical Student Education 499
Practicing Clinicians 500
Institutional Simulation Programs 501

74042_CH00_FMXX_6181.indd 17 8/10/12 7:34 AM


xviii Contents

Conclusion 502
References 503
Chapter 35 Moving from Traditional Informed Consent to Shared Patient–Provider
Decision Making 505
Shannon Flaherty
Introduction 505
The Medical and Legal Origins of Informed Consent 506
The Paternalistic Model for Patient–Provider Relationships 506
Informed Consent as a Response to Medical Paternalism 507
Recognition of the Legal Doctrine of Informed Consent in Medical
Practice 509
Developments in Medical Research and Practice: Shifting Toward
Patient Involvement 509
New Patient Decision-Making Models to Achieve Informed Consent 509
The Informed Decision-Making Model 510
The Professional-as-Agent Model 510
The Shared Decision-Making Model 510
Challenges and Benefits of Implementing a Shared Decision-Making Model 512
Challenges Implementing the Shared Decision-Making Model 512
Challenges Related to Communication: The Patient–Provider
Relationship 512
Provider Concerns Regarding Additional Time with Patients 513
Resources Needed to Implement Communication Tools 513
Benefits of Implementing a Shared Decision-Making Model 513
Suggestions for Improved Implementation of Shared Decision Making 515
Improving Provider Education 515
Improving Patient Education 515
Personalizing Patient Consent Forms 515
The Future of Informed Consent and Shared Decision Making 516
References 517
Chapter 36 Trust, Disclosure, Apology: How We Act When Things Go Wrong Has an
Impact on Patient Safety 521
Keith Siddel, MBA, JD, PHD
Trust 522
Disclosure 522
Apology 524
Outcomes 525
Conclusion 527
References 527
Chapter 37 Why, What, and How Ought Harmed Parties Be Told? The Art, Mechanics,
and Ambiguities of Error Disclosure 531
John D. Banja, PhD
Why Error Disclosure Is a Moral Imperative 532
How to Communicate Harm-Causing Error 533
Consideration 1: The Initial Contact 534

74042_CH00_FMXX_6181.indd 18 8/10/12 7:34 AM


Contents xix

Consideration 2: The Meeting Setting 535


Consideration 3: Who Should Be Present? 536
Consideration 4: Framing the Disclosure 537
Consideration 5: How to Talk 538
Consideration 6: Empathizing 539
Consideration 7: Follow-up 540
What Is Required for a Patient-Centered Policy on Error Disclosure? 541
A Final Point 542
References 542
Chapter 38 Moving Beyond Blame to Create an Environment That Rewards
Reporting 545
Doni Hass, RN

Chapter 39 The Role of Ethics and Ethics Services in Patient Safety 551
Erin A. Egan, MD, JD
Principles of Clinical Medical Ethics: Beneficence, Paternalism,
Nonmalificence, Justice, and Fiduciary Duties 552
Ethics Committees and Consultation Services 554
Patient Safety as an Ethical Issue 555
Specific Applications of Ethics in Particular Situations 557
Medical Mistakes 557
Provider Impairment and Incompetence 557
Informed Consent 558
Conclusion 558
Notes 558
Chapter 40 Telemedicine—Risk Management and Patient Safety 561
John Blum, JD, MHS and Doni McCoy, JD, LLM
Definitions 561
Major Variables for Risk Management/Patient Safety 562
Medical Liability 562
Practice Standards and Guidelines 566
Privacy/Security Considerations 566
Key Federal and State Regulatory Concerns 569
Conclusion 575
References 576
Chapter 41 The Criminalization of Medical Malpractice from Past to Present and the
Implications on Patient Safety and Voluntary Error Reporting 579
Laverne Largie, JD, LLM
Introduction 579
History of Criminalizing Medical Malpractice 579
The AMA’s Position on Criminal Prosecution May Limit Appropriate
Accountability 582
How Severe Cases of Medical Malpractice are Handled Today: An Analysis
Surrounding the Medical Care Resulting in the Death of Michael Jackson
and Anna Nicole Smith 583
The Difference Between Civil and Criminal Prosecution 584

74042_CH00_FMXX_6181.indd 19 8/10/12 7:34 AM


xx Contents

The Impact That Criminalizing Medical Malpractice Has on Patient


Safety and Voluntary Error Reporting 586
Should More Acts of Negligence Be Considered Criminal? 587
Conclusion 588
References 589
Chapter 42 Aligning Patients, Payers, and Providers: Bringing Quality and Safety
into the Reimbursement Equation 591
Caitlin Podbielski, JD
Introduction 591
Identifying the Variables and Constants 591
Defining the Relevant Terms 592
Formulating Reform Objectives 593
Paying for Performance Instead of Volume 595
Bundled Payment 595
Value-Based Purchasing 596
Medical Home 599
Recognizing Opportunities for Hybrid Models 600
Consolidating Stakeholders: The Emerging Trend of Payer–Provider
Entities 600
Combining Payment Mechanisms: Enhancing Capitation with
Incentive Payments 601
Conclusion 602
References 603

Index 605

74042_CH00_FMXX_6181.indd 20 8/10/12 7:34 AM


PREFACE

Tackling the second edition of Patient Safety Yet the ability or the willingness to translate
Handbook initially seemed like a relatively this knowledge into strategies that yield posi-
simple proposal. The first edition, which was tive change seems to lag far behind.
released in 2004, was actually conceptualized I have read the many articles and commen-
shortly after the landmark IOM report To Err Is taries on safety since the release of the IOM
Human made public what many clinicians, ad- report: some suggesting that great progress has
ministrators, and patients already knew: that been made and others (probably equal in num-
healthcare systems were poorly designed, ber) lamenting the fact that little progress has
preventable errors occurred frequently, and been made. In fact, both are probably true. We
people who entrusted their lives to providers know a great deal more about the complexities
and systems that promised a great outcome of the healthcare delivery system that predis-
were too frequently harmed or killed. pose individuals to err, we know that leadership
The science of safety was relatively nascent. is key in setting an agenda for change and in
Early leaders in the field such as Dr. Lucian aligning safety with the core vision and values
Leape and James Reason helped us all to begin of the organization, and we know that change
thinking differently about why the healthcare (even some of the seemingly simple things) is
system was so prone to error and how the sci- extremely hard to bring about and sustain in a
ence of safety (borrowed from other high haz- culture steeped in tradition and hierarchy.
ard industries) might be applied to health care Many providers continue to demand more
to better understand the root causes of error and better data and fail to appreciate that they
and to identify potential solutions for solving probably already have more than is necessary
specific safety problems. Early on, one of the to begin the process of change. We have all
recommendations offered by the drafters of learned that you can avoid the inevitable for a
the IOM report—to fund research to advance long time by simply asking for more proof. In
the science and study of safety—took root, my work with many hospitals, it is clear that it
and research into the most common types of is far easier to continue to study the problem
errors and to their etiology flourished. I would than to actually fix it and it is also easy to jus-
guess there are very few healthcare providers tify the limited effort to focus on safety by de-
who are not familiar with the common causes scribing the current conditions and challenges
of medication errors, the reasons wrong-sided faced by the healthcare industry, which often
procedures continue to happen, and the eco- seem to compete with the safety agenda.
nomic and emotional impact that preventable Clearly, many individuals and organizations
errors have on our healthcare delivery system. have provided great leadership to stimulate the

xxi

74042_CH00_FMXX_6181.indd 21 8/10/12 7:34 AM


xxii Preface

safety agenda, but far too often the impetus advocate. Of course, patients must be the rea-
for change is yet another tragic event, another son we rededicate ourselves to changing the
loved one lost, and another group of providers unsafe and overly complex systems that often
devastated by their role in, or proximity to, give rise to error, and we must listen to them
an event where significant harm to a patient so we know what things are of greatest con-
is the result. We must do better, and real and cern to them. But we cannot make patients
lasting change will occur only when healthcare and family members responsible for patient
providers and organizations acknowledge that safety. I find it unnerving when campaigns
they must hold themselves and their peers ac- are launched asking patients to “speak up” to
countable for safety, they must stop making ask their caregivers if they have washed their
excuses as to why safety is not a priority in hands or to challenge patients to know how
their organizations or within their practices, to escalate a concern when their loved one
and they must be willing to change practices seems in peril. It is once again an attempt to
and behaviors that we now know are counter- shift responsibility away from those individu-
productive to a culture of safety. als who are responsible and in the best posi-
As both a clinician and a lawyer, I have been tion to lead the change to someone who is
intrigued by how often I still hear the excuse vulnerable, frightened, and oftentimes too ill
offered that “we can’t be more transparent . . . or too timid to be an advocate. My fear is we
we can’t share information about our own er- might further harm patients and their loved
rors and best practices . . . we can’t hold our ones after an error by intimating that, if only
peers accountable” because the legal system they had been more assertive or more de-
is “so unfair,” “so punitive,” so “likely to de- manding of their care providers, they could
liver an unfair or unjust verdict.” This excuse have avoided or prevented the error. This
continues to inhibit progress in many areas. shifting of our responsibility onto others adds
It also has the impact of allowing providers insult to injury and often fails to allow provid-
to blame someone or something else for the ers to uncover the true root cause of the prob-
problems that really are under the control of lem. Patients should expect that when they
the caregiver and the caregiving organization. entrust their care to a provider or an organiza-
It seems somewhat obvious that most pa- tion that reasonable, safe, and effective care
tients enter the legal system only after harm will be provided and that preventable errors
has occurred or information has been with- will indeed be prevented, without their need-
held. So undoubtedly a better strategy would ing to maintain constant vigilance to protect
be to take control of the environment that is their loved ones. The fact that so many people
under our control and recognize that the only now state they would never leave their loved
way to not be put at risk by the legal system ones alone in a hospital is a testament to how
is to develop strategies for keeping patients little faith the public has in us, and this needs
free from harm. For over 30 years, doing the to change.
opposite has not proven to be the solution. In addition, providers should know that
Some looking at the table of contents of this their role in advocating for patient safety and
book might be concerned that there are no their efforts at creating and sustaining per-
specific chapters representing the patient’s sonal and collective accountability will not
responsibility or the patient’s role in patient only yield benefits for their patient but also
safety. This was actually intentional. My po- for them. Errors are devastating to those expe-
sition on patient safety is that once again it riencing them and to their loved ones, but the
is first and foremost the responsibility of the toll they take on the providers involved is also
provider and of healthcare organizations. It devastating. Working as a provider in our cur-
is a responsibility that we cannot pass off to rent healthcare delivery system is physically
a patient or a concerned family member or and emotionally exhausting, and providers

74042_CH00_FMXX_6181.indd 22 8/10/12 7:34 AM


Preface xxiii

deserve to be in systems that support them change the way we educate physicians and
and that have processes in place to assure en- nurses so that they develop the competencies
sure both individual and collective success. needed to be safety champions. This recog-
If you read the first edition of Patient Safety nition of the need to create a measureable
Handbook, you will recognize that a number curriculum around safety is reinforced by the
of the chapters were retained because the tools available with this second edition, which
authors were actually ahead of the field and include specific learning objectives for each
the content of those chapters still provides a chapter, questions to test whether the most
necessary framework detailing the science of salient points were understood, and Microsoft
safety, the knowledge of error, and the role PowerPoint slides to review the highlights of
of various members of the healthcare team each chapter and to teach colleagues specific
in advancing a safety culture. More than half aspects of the topics presented.
of the chapters, however, are completely new It is my hope that the material provided
and reflect work that has been done over the in the second edition will enable you to see
past 10 years, along with specific strategies that while we are not yet where we need to
for making our systems, our providers, and be in making our systems safer, we are mak-
most importantly, our patients safer. Two new ing progress toward achieving safer and more
and important chapters address the need to transparent health care for all.

74042_CH00_FMXX_6181.indd 23 8/10/12 7:34 AM


74042_CH00_FMXX_6181.indd 24 8/10/12 7:34 AM
FOREWORD
Helen Haskell

For those outside the medical profession— language used when speaking to us. But the
and to a large extent, those inside it as well— standards they were following came with cav-
the reasons for becoming involved in patient ernous wiggle room, enough to accommodate
safety are most often personal, and not in a even the most egregious errors and then noth-
good way. For my husband and I, this involve- ing was done to catch them after they had oc-
ment was precipitated by the loss of our bril- curred. Not just the process but the structure
liant, vibrant 15-year-old son, Lewis, who died was rife with potential for harm. In this con-
from a cascade of medical errors following text, James Reason’s Swiss cheese metaphor—
elective surgery. another piece of our new knowledge—seemed
I will not go into detail, but suffice it to say little more than a euphemism. The system, so
that a boy we regarded as one of the outstand- implicitly trusted by so many, was simply not
ing young men of his generation was casually set up to accomplish its goal. From our per-
sacrificed to medication error, hierarchy, and spective, there were more holes than cheese.
misplaced arrogance—in short, to all the short- We saw only one way forward from this
comings of the teaching hospital. Lewis en- experience—to bring some good out of the
tered the hospital a healthy, athletic teenager disaster that had befallen us. That was the be-
wearing shorts and sandals in the last days of ginning of a journey of advocacy that has yet
a late South Carolina autumn. Four days later, to end. In many ways, we were typical of fami-
we emerged without him into the first bright, lies affected by medical harm. Like most, we
cold days of winter. His path in those few days sought to bring hope out of despair, and we
can be traced in half a sentence: two hours in thought that the legacy of our son and thou-
surgery, two and a half days in recovery, and a sands of others would be the immediate re-
day and a half in calamitous decline before he form of the system that had taken their lives.
died, unrescued, in his hospital bed. Through Our aspirations seem almost quaint from our
all this, our concerns and pleas for help had current perspective. But we believed that a
gone unheeded. system so out of sync with its own mission
As we worked through Lewis’s medical re- could surely be brought back to its intended
cords to reconstruct the decisions that had path by a small group of determined people
been made, we were taken aback by what we bent on doing the right thing.
found. Most chilling was the gradually dawn- This all took place at the end of 2000, a
ing realization that despite their ultimately le- year after the Institute of Medicine’s report
thal mistakes, most of our son’s caregivers had To Err Is Human. Hope was high in that mo-
acted strictly by the book, even down to the ment. The problem had been delineated, and

xxv

74042_CH00_FMXX_6181.indd 25 8/10/12 7:34 AM


xxvi Foreword

we had both the will and the outline of a plan this. The industry of health care has been al-
to change it. Rereading parts of the 2004 edi- lowed to function with too little accountability
tion of Patient Safety Handbook, one can still to its patients, its practitioners, and its com-
feel that hope. And yet, there and elsewhere, munities and in the process has often lost the
many people were already expressing dismay virtues of openness, honesty, and altruism
at the slow pace of reform. The fifth anniver- that the public thinks should be its hallmark.
sary and then the 10th passed with much Patients will also tell you that fragmentation
soul-searching. Few thought we had shown and high-volume medicine—lack of time with
significant change to be proud of. their providers—are among the most signif-
No one can say we have not made many icant drivers of patient harm. The patient
advances. We have put to rest—in most cir- voice is essential to solving these problems.
cles, at least—the idea that patient harm is Left unaddressed, these difficult, overarch-
not a problem. We have meaningful support ing questions have the potential to negate all
from government entities. We have dedicated that is achieved through other patient safety
champions both within and outside of the sys- programs.
tem. Thanks in large part to the path blazed The bottom line is that much remains to
by consumer advocates in many American be done. Patients and families continue to en-
states, we have the beginnings of a system of trust themselves to systems that are fraught
transparency that has the potential of giving with risks over which they often have no
patients a clearer idea of benefits and risks. power. Technical solutions, standardization,
And yet we still do not have a real-time pic- teamwork, improved communication, culture
ture of the extent of patient harm, and we change—these all are necessary, important,
do not know to what extent our efforts in the and transformative. But they are only parts of
past few years may or may not have helped a larger solution. Above all, we need to take
reduce it. on patient safety as an ethical challenge, one
Patients overwhelmingly see patient harm that pays careful attention to patient concerns
as an ethical issue, and those who think about and aspires to broad and innovative change
it see transparency as the essential underlying at a fundamental level. I urge you to read this
principle of reform. They are not mistaken in volume with that in mind.

74042_CH00_FMXX_6181.indd 26 8/10/12 7:34 AM


CONTRIBUTORS

Laura Ashpole, JD Keshia Carswell


Loyola University Chicago Loyola University Chicago
School of Law School of Law
Beazley Institute for Health Law and Policy Beazley Institute for Health Law and Policy
Chicago, IL Chicago, IL

Barbara Balik, RN, EdD Carolyn Chapman, JD


CEO, Common Fire Attorney
Albuquerque, NM Chicago, IL

John Banja, PhD Barbara A. Connelly, RN, MJ


Professor, Department of Rehabilitation Director of Risk Management, MCWAH
Medicine Graduate Medical Education
Medical Ethicist, Center for Ethics Milwaukee, WI
Director, Ethics Section: Atlanta Clinical and
Translational Science Institute Richard I. Cook, MD
Emory University Royal Institute of Technology
Atlanta, GA Sweden

Raj Behal, MD, MBA George R. Cybulski, MD, FACS


Assistant Professor Associate Professor of Neurological Surgery
Associate Chief Medical Officer Northwestern University
Biostatistics and Biomedical Informatics Task Feinberg School of Medicine
Force Chicago, IL
Rush University Medical Center
Chicago, IL Erin Egan, MD, JD
Assistant Professor of Medicine
John Blum, JD, MHS Division of General Internal Medicine
John J. Waldron Research Professor University of Colorado
Loyola University Chicago Denver, CO
School of Law
Beazley Institute for Health Law and Policy
Chicago, IL

xxvii

74042_CH00_FMXX_6181.indd 27 8/10/12 7:34 AM


xxviii Contributors

David A. Ehlert, PharmD John Hidley, MD


Vice President, Pharmacy Practice Psychiatrist
Resources Behavioral Science Technology
McKesson Pharmacy Optimization Ojai, CA
Golden Valley, MN
Marina Karp, MJ
Kathleen Ferket, RN, MSN, APN Beazley Institute for Health Law and Policy
Executive Director, Patient Care Support Loyola University Chicago
Northwest Community Hospital School of Law
Chicago, IL Chicago, IL

Shannon Flaherty Mark Keroack, MD, MPH


Beazley Institute for Health Law and Policy Chief Physician Executive, Baystate Health
Loyola University Chicago President, Baystate Medical Practices
School of Law Springfield, MA
Chicago, IL
G. Eric Knox, MD, FACOG
John Fromson, MD Minneapolis, MN
Vice President for Professional Development
Massachusetts Medical Society Mahendra S. Kochar, MD, MS, MBA, JD
Clinical Instructor in Psychiatry Associate Dean for Graduate Medical
Harvard Medical School Education
Boston, MA University of California, Riverside School of
Medicine
Kathy Gerwig Riverside, CA
Vice President
Employee Safety, Health and Wellness and Thomas R. Krause, PhD
Environmental Stewardship Officer Behavioral Science Technology
Kaiser Permanente Ojai, CA
Oakland, CA
Louise LaFramboise, PhD, RN
Doni Hass, RN Associate Professor and Director
Stuart, FL Baccalaureate Program
University of Nebraska College of Nursing
David Hewett, MD Omaha, NE
Assistant Medical Director (Litigation)
Winchester Eastleigh Healthcare Laverne Largie, JD, LLM
NHS Trust Woodstock, MD
England, United Kingdom
Richard Lauve, MD
Gerald B. Hickson, MD Founder and Principal
Assistant Vice Chancellor for Health Affairs L & A Consulting
Associate Dean for Faculty Affairs Baton Rouge, LA
Joseph C. Ross Chair in Medical Education
and Administration Lucian Leape, MD
Director, Center for Patient and Professional Adjunct Professor of Health Policy
Advocacy Department of Health Policy and Management
Vanderbilt University Medical Center Harvard School of Public Health
Nashville, TN Boston, MA

74042_CH00_FMXX_6181.indd 28 8/10/12 7:34 AM


Contributors xxix

Allison Caravana Lilly, MSW, LICSW, CEAP Laura B. Morgan, JD


Employee Assistance Program Loyola University Chicago
Brigham and Women’s Hospital School of Law
Boston, MA Beazley Institute for Health Law and Policy
Chicago, IL
Roy Magnusson, MD, MS, FACEP
Associate Dean for Clinical Affairs John J. Nance, JD
Chief Medical Officer John Nance Productions
John A. Burns School of Medicine Seattle, WA
University of Hawaii
Honolulu, HI Dennis O’Leary, MD
President Emeritus
Shawn Mathis, JD, LLM The Joint Commission
Staff Attorney Oak Brook Terrace, IL
New Mexico Legislative Council Services
Santa Fe, NM James Pichert, PhD
Codirector, CPPA; Professor, Medical Educa-
Doni M. McCoy, JD, LLM tion and Administration
Atlanta, GA Vanderbilt University Medical Center
Nashville, TN
Wendy Tuzik Micek
Market Director, Nursing Science and Magnet Katherine A. Pischke-Winn, MBA, RN
Advocate Christ Medical Center Director, Clinical Innovation and Research
Oak Lawn, IL Advocate Good Shepherd Hospital
Barrington, IL
Sarah Mick, JD, LLM
Associate Caitlin Podbielski, JD
Dorsey & Whitney Beazley Institute for Health Law and Policy
Des Moines, IA Fellow 2012
Loyola University Chicago
Connie Miller, PhD, RN School of Law
Assistant Professor Chicago, IL
Director, LRC Omaha Division
UNMC College of Nursing Grena Porto, RN, MHA, ARM, CPHRM
Omaha, NE Principal
QRS Healthcare Consulting, LLC
Karla M. Miller, PharmD, BCPP Hockessin, PA
Director of Medication Usage and Safety
Hospital Corporation of America Marsha Regenstein, PhD, MCP
Nashville, TN Director
National Public Health and Hospital Institute
Julianne Morath, RN, MS The Commonwealth Fund
Chief Quality and Patient Safety Officer Washington, DC
Vanderbilt University Medical Center
Nashville, TN David Resnik, JD, PhD
Bioethicist and NIEHS IRB Chair
National Institutes of Health
Research Triangle Park, NC

74042_CH00_FMXX_6181.indd 29 8/10/12 7:34 AM


xxx Contributors

Emily Rhinehart, RN, MPH, CIC, CPHQ Robert Simon, EdD, CPE
Vice President Education Director
Chartis Insurance Center for Medical Simulation
Atlanta, GA Boston, MA

Karlene H. Roberts, PhD Kathleen Rice Simpson, PhD, RNC, FAAN


Professor Emeritus Perinatal Clinical Nurse Specialist
Haas School of Business St. John’s Mercy Medical Center Labor and
University of California Berkeley Delivery
Berkeley, CA St. Louis, MO

Bethany Robertson, DNP, CNM, NM David Van Stralen, MD


Assistant Professor, Clinical Department of Pediatrics
Academic Lead for Technology Innovation Loma Linda University Medical Center
Emory University Loma Linda, CA
Atlanta, GA
Karen M. Stratton, PhD, RN, NE-BC
Steven Rough, MS, RPh Clinical Assistant Professor and Coordinator,
Director of Pharmacy Graduate Administrative Studies Program
University of Wisconsin Hospital and Clinics Department of Health Systems Science
Clinical Assistant Professor UIC College of Nursing
University of Wisconsin School of Pharmacy Chicago, IL
Madison, WI
Charles Vincent, MD
Mary Salisbury, RN, MSN Professor of Psychology
President University College
The Cedar Institute, Inc. London, England
North Kingstown, RI
David D. Woods, PhD
Manisha Shaw, MBA, RCP Professor
Chief Operating Officer Ohio State University
National Patient Safety Foundation Institute for Ergonomics
Boston, MA Columbus, OH

Gwen Sherwood, PhD, RN, FAAN Barbara J. Youngberg, JD, MSW, BSN,
Professor and Associate Dean for Academic FASHRM
Affairs Visiting Professor
University of North Carolina at Chapel Hill Academic Director On-Line Legal Education
School of Nursing Loyola University Chicago
Chapel Hill, NC School of Law
Beazley Institute for Health Law and Policy
Keith Siddel, MBA, JD, PhD Chicago, IL
Chief Marketing Officer
Health Revenue Assurance Associates Kuo (Frank) Yu, PhD
Plantation, FL Assistant Professor
City University of Hong Kong
Kowloon Tong
Kowloon, Hong Kong

74042_CH00_FMXX_6181.indd 30 8/10/12 7:34 AM

You might also like