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Patient Safety and Quality Improvement in Healthcare

Rahul K. Shah  •  Sandip A. Godambe Editors

Patient Safety and Quality Improvement in Healthcare A Case-Based Approach

Editors Rahul K. Shah Children’s National Health System Washington, DC USA

Sandip A. Godambe Children’s Hospital of The King’s Daughters Norfolk, VA USA

ISBN 978-3-030-55828-4    ISBN 978-3-030-55829-1 (eBook) https://doi.org/10.1007/978-3-030-55829-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Foreword

Emily died in our hospital. She was 3 years old. She passed away following a preventable medical error. As recently as 20 years ago, an event such as this might only show up when a grieved family brings suit against the hospital and providers. Yet today, the national dialogue and focus on patient safety and transparent outcomes has dramatically changed. In most hospitals, not only would Emily’s passing be analyzed in meticulous detail, but the results would be promulgated within and across the hospital to ensure that providers and the hospital system minimize any chance of recurrence. Further, with resilience engineering and the growing concept of Safety II, hospital systems and individuals may even learn to anticipate the circumstances that predispose to preventable errors [1–3] and prevent them before they occur. A plethora of texts exist that are filled with theory and concepts intending to teach about making sure “Emily” never happens again—in any of our hospitals. In their text, Shah and Godambe have taken the conversation and teaching about quality and safety to a