Joint Commission Resources (JCR) has announced the release of the book, “The Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient Harm.” JCR is a not-for-profit affiliate of The Joint Commission.
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, edited by patient safety expert Albert Wu, M.D., M.P.H., a professor at the Johns Hopkins Bloomberg School of Public Health and a physician at The Johns Hopkins Hospital, features 15 detailed case studies from a variety of clinical disciplines and specialties that show how health care organizations can use close calls to identify, investigate and solve patient safety problems.
“Working with the authors for this book showed me just how useful close calls can be for uncovering flaws in the ways we take care of patients – and in suggesting ways to fix them to protect patients from harm,” says Dr. Wu.
In the book’s foreword, James Reason, Ph.D., the renowned expert in human error, states that close calls are “free lessons” about how patient harm occurs. “Chronicling, analyzing, debating and disseminating stories about close calls are prerequisites for achieving the unrelenting vigilance and informed wariness that are vital steps along the path to improving patient safety.”
Robert M. Wachter, M.D., University of California, San Francisco, states, “This superb book tells us why analyzing close calls is so important to patient safety and shows us how to do it. It should be on the bookshelf of everyone interested in keeping patients safe.”
“The Joint Commission’s view of patient safety incidents includes close calls, and this book illustrates the reasons why close calls are so important to the risk reduction process,” says Paul M. Schyve, M.D. senior vice president, Healthcare Improvement, The Joint Commission.
“If we want to get serious about patient safety, conducting root cause analyses of close calls is just as important as the analyses of sentinel events in which actual harm has come to a patient. Close calls are key opportunities to uncover vulnerabilities in a system and shouldn’t be overlooked in a safety culture.”
Source:Joint Commission Resources