Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...
Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ... Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...
- Billings CE. The NASA Aviation Safety Reporting System: Lessons Learned FromVoluntary Incident Reporting. In: Proceedings of enhancing patient safety and reducing errorsin health care. Chicago: National Patient Safety Foundation; 1998:97-100.- Björnberg A, Cebolla Garrofé B, Lindblad S. Euro Health Consumer Index 2009. HealthConsumer Powerhouse; 2009.- Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al.Views of practicing physicians and the public on medical errors. N Engl J Med.2002;347(24):1933-40.- Blijham GH, Mütter E. Samenspel en samenklank. De besturingsfilosofie enorganisatiestructuur van het UMC Utrecht. Houten: Bohn Stafleu van Loghum; 2010.- BMJ 2000;320 (18 March)- Bont A de, Jerak S, Zuiderant T, Bal R, Meurs P. Veiligheid in de zorg. Achtergrondstudie bijde Staat van de Gezondheidszorg 2009. Onderzoeksrapport 2009.02. Rotterdam: InstituutBeleid & Management Gezondheidszorg; november 2009.- Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP,Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients.Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-6.- Brown C, Lilford R. Evaluating service delivery interventions to enhance patient safety.BMJ. 2009;338:159-63.- Brown JS, Duguid P. Balancing act: how to capture knowledge without killing it. HBR.May-June 2000.- Bruijn H de. Managers en professionals. Den Haag: Academic Service; 2008.- Bruijn JA de, Heuveltop EF ten. Management in netwerken. Derde druk. Den Haag: Boom;2007.- Bruijn, H de. Heuvelhof, E ten. Veld, R. in ’t. Procesmanagement. Over procesontwerp enbesluitvorming. 3e druk. Den Haag: Academic Service; 2008.- Bruun Jensen C. Sociology, Systems, and (Patient) Safety: Knowledge Translations inHealthcare Policy. Sociology of Health & Illness. 2008;30(2):309-24.- Buchanan DA, Addicott R, Fitzgerald L, Ferlie E, Baeza JI. Nobody in charge: Distributedchange agency in healthcare. Human Relations. 2007;60(7):1065 - 90.- Buchman TG, Cassell J, Ray SE, Wax ML. Who should manage the dying patient? Rescue,shame, and the surgical ICU dilemma. J Am Coll Surg. 2002;194(5):665-73.- Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of amedical emergency team on reduction of incidence of and mortality from unexpectedcardiac arrests in hospital: preliminary study. BMJ. 2002;324(7334):387-90.- Casey SM. Set Phasers on Stun: And Other True Tales of Design, Technology, and HumanError. Santa Barbara, CA: Aegean Publishing Company; 1993.- Chan Kim W, Mauborgne R. Fair process: managing in the knowledge economy. HBR.Januari 2003.Patiëntveiligheid, de rol van de bestuurder 361
- Chapman P, Underwood G. Forgetting near-accidents: the roles of severity, culpability andexperience in the poor recall of dangerous driving situations. Applied Cognitive Psychology.2000;14: 31-44.- Clarke JR, Lerner JC, Marella W. The role for leaders of health care organizations in patientsafety. Am J Med Qual. 2007;22(5):311-8.- Connor M, Duncombe D, Barclay E, Bartel S, Borden C, Gross E, et al. Creating a fair andjust culture: one institution’s pat toward organizational change. Jt Comm J Qual Patient Saf.2007;33(10):617-24.- Cooper JB, Gaba DM, Liang B, Woods D, Blum LN. National Patient Safety Foundationagenda for research and development in patient safety. MedGenMed. 2000;2(3):E38.- Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model ofreasoning. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35.- Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incidentreporting system does not detect adverse drug events: a problem for quality improvement.Jt Comm J Qual Improv. 1995;21(10):541-8.- Davis P, Lay-Yee R, Schug S, Briant R, Scott A, Johnson S, Bingley W. Adverse eventsregional feasibility study: indicative findings. N Z Med J. 2001;114(1131):203-5.- Dawson P, Buchanan D. The way it really happened: competing narratives in the politicalprocess of technological change. Human Relations. 2005;58(7):845-65.- Dawson P. Reshaping change: A processual perspective. London: Routledge; 2003.- De Volkskrant. Inspectie sluit afdeling Intensive Care in Weert. 18 februari 2005.- Dekker S. The field guide to understanding human error. Hampshire: Ashgate; 2006.- Department of Veterans’ Affairs. Profile VA National Center for Patient Safety 2006.[document on internet]. Washington: Department of Veterans’ Affairs;2006 [cited 2009August 8]. Available from: www.va.gov/NCPS/Pubs/2006Profile.pdf- DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care Failure Mode and EffectAnalysis: the VA National Center for Patient Safety’s prospective risk analysis system. JtComm J Qual Improv. 2002;28(5):248-67.- Donabedian A. Explorations in quality assessment and monitoring. Vol. II. The criteria andstandards of quality. Ann Arbor, Michigan: Health Administration Press; 1982.- Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-8.- Donabedian, A. 1966. Evaluating the Quality of Medical Care. Milbank Memorial FundQuarterly: Health and Society. 44(3; pt. 2):166–203.- Drucker P. The Landmarks of Tomorrow. London: Heinemann; 1959.- Drucker P. Management Challenges for the 21st Century. New York: Harper Collins; 1999.- Dückers MLA. Changing hospital care: evaluation of a multi-layered organisationaldevelopment and quality improvement programme. Utrecht: NIVEL; 2009.- Edmonson AC. The competitive imperative of learning. HBR. July-August 2008:60-7.- EMGO instituut/NIVEL. Onbedoelde schade in Nederlandse ziekenhuizen. Dossieronderzoekvan ziekenhuisopnames in 2004. EMGO/NVEL; 2007.362Referenties
- Page 311 and 312: Zo konden de professionals zich erv
- Page 313 and 314: Inbreng van professionals leidde to
- Page 315 and 316: werd bedreigd. Het moest voor manag
- Page 317 and 318: - De deelnemers hadden een exit-opt
- Page 319 and 320: nemen of dat er een beslissing werd
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- Page 327 and 328: van de medewerkers die een SIRE had
- Page 329 and 330: - Initiatiefnemer is bij voorbaat v
- Page 331 and 332: 3 SamenvattingDit onderzoek richt z
- Page 333 and 334: alleen in de juiste onderlinge verh
- Page 335 and 336: 4 BeschouwingInleidingIn de vorige
- Page 337 and 338: ken die aan onveiligheid bijdroegen
- Page 339 and 340: Nuancering van de rol van processtu
- Page 341 and 342: de uitkomsten van dit onderzoek gen
- Page 343 and 344: • In dit onderzoek is gebleken da
- Page 346 and 347: Appendix AReferentiesSamenvattingSu
- Page 348 and 349: 1. Inleiding1.1 Voorgeschiedenis st
- Page 350 and 351: instellen van een Kerncommissie Pat
- Page 352 and 353: 2.4 UitwerkingEr moet één centraa
- Page 354 and 355: - Patiënten Service/ klachtenburea
- Page 356 and 357: Haar taken zijn:1 Het gevraagd en o
- Page 358 and 359: maatschappij kunnen behouden zonder
- Page 360 and 361: 6 Samenstelling Kerncommissie Pati
- Page 364 and 365: - Evans RG, Cardiff K, Sheps S. Hig
- Page 366 and 367: - Linkin DR, Sausman C, Santos L, L
- Page 368 and 369: - Stolper E, van Bokhoven M, Houben
- Page 370 and 371: - Zwart DLM, van Rensen ELJ, Verhei
- Page 372 and 373: 3 Prescriptief- Hoe kunnen de uitko
- Page 374 and 375: en dus veilige, zorg te organiseren
- Page 376 and 377: Elke casus bestond uit een aantal o
- Page 378 and 379: ling op de bestaande theorie over p
- Page 380 and 381: - Inbreng;(alle betrokkenen moeten
- Page 382 and 383: 3 Prescriptive- How can the results
- Page 384 and 385: Side-effects of professionalismThe
- Page 386 and 387: - Root Cause Analysis (RCA), a meth
- Page 388 and 389: ing networks, writing reports) so t
- Page 390 and 391: Dankwoord- Allereerst wil ik mij pr
- Page 392 and 393: - De levenshouding die ertoe geleid
- Page 394 and 395: PublicatielijstPublicaties - boeken
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- Chapman P, Un<strong>de</strong>rwood G. Forgetting near-acci<strong>de</strong>nts: the <strong>rol</strong>es of severity, culpability an<strong>de</strong>xperience in the poor recall of dangerous driving situations. Applied Cognitive Psychology.2000;14: 31-44.- Clarke JR, Lerner JC, Marella W. The <strong>rol</strong>e for lea<strong>de</strong>rs of health care organizations in patientsafety. Am J Med Qual. 2007;22(5):311-8.- Connor M, Duncombe D, Barclay E, Bartel S, Bor<strong>de</strong>n C, Gross E, et al. Creating a fair andjust culture: one institution’s pat toward organizational change. Jt Comm J Qual Patient Saf.2007;33(10):617-24.- Cooper JB, Gaba DM, Liang B, Woods D, Blum LN. National Patient Safety Foundationagenda for research and <strong>de</strong>velopment in patient safety. MedGenMed. 2000;2(3):E38.- Croskerry P. Clinical cognition and diagnostic error: applications of a dual process mo<strong>de</strong>l ofreasoning. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35.- Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The inci<strong>de</strong>ntreporting system does not <strong>de</strong>tect adverse drug events: a problem for quality improvement.Jt Comm J Qual Improv. 1995;21(10):541-8.- Davis P, Lay-Yee R, Schug S, Briant R, Scott A, Johnson S, Bingley W. Adverse eventsregional feasibility study: indicative findings. N Z Med J. 2001;114(1131):203-5.- Dawson P, Buchanan D. The way it really happened: competing narratives in the politicalprocess of technological change. Human Relations. 2005;58(7):845-65.- Dawson P. Reshaping change: A processual perspective. London: Routledge; 2003.- De Volkskrant. Inspectie sluit af<strong>de</strong>ling Intensive Care in Weert. 18 februari 2005.- Dekker S. The field gui<strong>de</strong> to un<strong>de</strong>rstanding human error. Hampshire: Ashgate; 2006.- Department of Veterans’ Affairs. Profile VA National Center for Patient Safety 2006.[document on internet]. Washington: Department of Veterans’ Affairs;2006 [cited 2009August 8]. Available from: www.va.gov/NCPS/Pubs/2006Profile.pdf- DeRosier J, Stalhandske E, Bagian JP, Nu<strong>de</strong>ll T. Using health care Failure Mo<strong>de</strong> and EffectAnalysis: the VA National Center for Patient Safety’s prospective risk analysis system. JtComm J Qual Improv. 2002;28(5):248-67.- Donabedian A. Explorations in quality assessment and monitoring. Vol. II. The criteria andstandards of quality. Ann Arbor, Michigan: Health Administration Press; 1982.- Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743-8.- Donabedian, A. 1966. Evaluating the Quality of Medical Care. Milbank Memorial FundQuarterly: Health and Society. 44(3; pt. 2):166–203.- Drucker P. The Landmarks of Tomorrow. London: Heinemann; 1959.- Drucker P. Management Challenges for the 21st Century. New York: Harper Collins; 1999.- Dückers MLA. Changing hospital care: evaluation of a multi-layered organisational<strong>de</strong>velopment and quality improvement programme. Utrecht: NIVEL; 2009.- Edmonson AC. The competitive imperative of learning. HBR. July-August 2008:60-7.- EMGO instituut/NIVEL. Onbedoel<strong>de</strong> scha<strong>de</strong> in Ne<strong>de</strong>rlandse ziekenhuizen. Dossieron<strong>de</strong>rzoek<strong>van</strong> ziekenhuisopnames in 2004. EMGO/NVEL; 2007.362Referenties
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