...http://www.nap.edu/catalog/9728.html We ship printed books within 1 business day; personal PDFs are available immediately. To Err Is Human: Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine ISBN: 0-309-51563-7, 312 pages, 6 x 9, (2000) This PDF is available from the National Academies Press at: http://www.nap.edu/catalog/9728.html Visit the National Academies Press online, the authoritative source for all books from the National Academy of Sciences, the National Academy of Engineering, the Institute of Medicine, and the National Research Council: • Download hundreds of free books in PDF • Read thousands of books online for free • Explore our innovative research tools – try the “Research Dashboard” now! • Sign up to be notified when new books are published • Purchase printed books and selected PDF files Thank you for downloading this PDF. If you have comments, questions or just want more information about the books published by the National Academies Press, you may contact our customer service department tollfree at 888-624-8373, visit us online, or send an email to feedback@nap.edu. This book plus thousands more are available at http://www.nap.edu. Copyright © National Academy of Sciences. All rights reserved. Unless otherwise indicated, all materials in this PDF File are copyrighted by the National Academy of Sciences. Distribution, posting, or copying...
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...Certificate), arguably your first CV point containing the word „marketing‟. We also prepare you for the all important summer internships by means of experience sharing, briefing about the companies, and finally by organizing mock GDs and interviews for the entire batch. You can connect with us via our Facebook page (facebook.com/mPowerIIMK) and/or our blog (mpower.iimk.ac.in). You can also write to us at mpower@iimk.ac.in. Some questions to be covered... Some questions to be covered... Some questions to be covered... Some questions to be covered... Some questions to be covered... \m/arketing, what is it? People say marketing = selling. Is it? Of all the things, what all can be marketed? Who are the gentlemen who market anyway? Err… what‟s this STP then? Right…so all gentlemen market the same way? \m/arketing, what isisisit? \m/arketing, what it?it? \m/arketing, what isisit? \m/arketing, what it? \m/arketing, what Marketing has myriad+1 definitions. The +1th definition, which is the shortest of the lot is, understandably, the most frequently used as well. Marketing, it says, is “meeting needs profitably.” Among the myriad others, this one by the American Marketing Association is believed to be the most complete: “Marketing is an organizational function and a set of processes...
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...of physical hazards which includes excessive noise and vibration, inadequate lighting, exposure to radiation, slippery surfaces, etc., environmental hazards is another reason such pollution, storm, earthquakes, etc., as well as human factors, even no safety regulations and lastly poor communication within, between, and among various trades working on a job site. An accident is defined as an unintended and unplanned occurrence that results in a negative effect. Accident causation theories have been developed in an attempt to predict accidents and thus prevent their occurrence. So far there has not been an accident prevention theory that has been universally accepted. They have however served in some preventative measures in some cases. For the record, an accident is technically anything that happens by chance or misfortune. This definition provides two important points. First, accidents are unavoidable as a whole; the chance of one occurring will virtually always be present. Second, the chance of an accident occurring is a variable that can be changed. While it is impossible to prevent all accidents, it is possible to decrease their rate of occurrence. Accident causation theories are mainly categorized into seven kinds. We have the domino theory, human factors theory, accident / incident theory, epidemiological theory, systems theory, combination theory, and lastly behavioral theory. Domino Theory is among...
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...November 1999 I N S T I T U TE OF M E D I C I N E Shaping the Future for Health TO ERR IS HUMAN: BUILDING A SAFER HEALTH SYSTEM H ealth care in the United States is not as safe as it should be--and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS. Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Among the problems that commonly occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities. High error rates with serious consequences are most likely to occur in intensive care units, operating rooms, and emergency departments. Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (in cluding the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors...
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...Public Disclosure Authorized Public Disclosure Authorized 72506 Program Keluarga Harapan Main Findings from the Impact Evaluation of Indonesia’s Pilot Household Conditional Cash Transfer Program Public Disclosure Authorized Public Disclosure Authorized World Bank Office Jakarta June 2011 Acknowledgments This report was prepared by the Poverty Team, part of the Poverty Reduction and Economic Management (PREM) group in the World Bank Office Jakarta. Vivi Alatas, the Task Team Leader, led the analytical activities and oversaw the preparation of the report. She was supported by a team that included: Nur Cahyadi, Elisabeth Yunita Ekasari, Sarah Harmoun, Budi Hidayat, Edgar Janz, Jon Jellema, Hendratno Tuhiman, and Matthew Wai-Poi. The University of Gadjah Mada (UGM), Center for Public Policy Studies, implemented the baseline and final survey. The analysis for this evaluation was based on survey data that was collected and processed by some 860 enumerators and researchers. The survey work was led and overseen by Susan Wong. This report also draws from the findings of the resulting 2007 baseline survey report written by Robert Sparrow, Jossy Moeis, Arie Damayanti and Yulia Herawati. The Center for Health Research at the University of Indonesia, with the support of partner universities across the country, prepared a report in 2010 on the implementation of Program Keluarga Harapan (PKH), based on qualitative and quantitative spot-checks of the program. In addition...
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...Running head: IMPROVING HEALTHCARE QUALITY AND PATIENT SAFETY !1 ! ! ! ! Quality Improvement Techniques: Improving Healthcare and Patient Safety ! HMGT 320 ! February 9, 2014 ! ! ! ! ! ! ! Quality Improvement Techniques in a Healthcare Setting !2 ! There is a great need to improve on the quality of healthcare we are providing to patients and it is a necessity to improve on patents safety also. Quality health care is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Chassin, 2006). According to the Institute of Medicine, To Err Is Human, the majority of medical errors result from defective systems and procedures, not individuals. Processes that are ineffective and flexible, changing case mix of patients, health insurance, differences in provider education and experience, and numerous other factors contribute to the difficulty of health care. With this in mind, today’s health care industry functions at a lower level than it can and should, and it put forth the following six aims of health care: effective, safe, patient-centered, timely, efficient, and equitable (Ferlie, 2005). The aims of effectiveness and safety are targeted through various processes that will measure whether providers of health care perform processes that have been demonstrated to achieve the desired aims and avoid those processes that are given toward maltreatment...
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...COVER PAGE EXECUTIVE SUMMARY TABLE OF FIGURES TABLE OF CONTENT 1. INTRODUCTION (250) 2.1 History of the resort 2.2 Vision-Mission-Value-Culture 2. SITUATIONAL ANALYSIS 3.3 Stakeholder matrix analysis 3.4 TOWS matrix 3. ISSUES (400) 4.5 Micro issues 4.6 Macro issues 4. SUSTAINABLE PRACTICES (600) 5. IMPACTS (600) 6.7 On the organization (8 JA, 1 Framework) 6.8 On the guest experience (8 JA, 1 Framework) 6. CHALLENGES(400) 7. RECOMMENDATIONS- STRATEGIC PLANNING- Grant Chart(200-250) 8. CONCLUSION (250) APPENDICES 1. INTRODUCTION 1.1 Overview of MGM Resorts International 1986 2000 2010 1986 2000 2010 MGM was incorporated as an company MGM was incorporated as an company MGM Grand and Mirages Resorts was merged into MGM Mirage MGM Grand and Mirages Resorts was merged into MGM Mirage MGM Mirage changed into MGM Resorts International MGM Mirage changed into MGM Resorts International Figure 1. Timeline of MGM Resorts International (Bolton 2014) MGM Resort International (MGM), which is based in Nevada, USA, is one of the global leading companies in hospitality and entertainment industry. (Bolton 2014). It owns and operates 13 properties across the world, some of which are MGM Grand, Bellagio, Mandalay Bay, Mirage and holds 50% investments in four other properties including CityCenter. Besides, MGM has 51% interest in MGM China Holdings Limited owning...
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...Role Development of the Advanced Practice Nurse 1 Role Development of the Advanced Practice Nurse Julie L. Mitchell RN, BSN Grantham University NUR 506 Advanced Practice Nursing Dr. Ludella Brown DNP February 3, 2014 Role Development of the Advanced Practice Nurse 2 The role of the Advance Practice Nurse has changed drastically over the years as we have moved closer to a goal of professionalism, recognized by society. Professionalism in nursing has been evolving since the days of Florence Nightingale. For most of the 20th century nursing was considered a profession in progress by sociologists (Bucher & Strauss, 1961; Etzioni, 1969). Nurses have been striving toward professionalism and the autonomy that defines it for decades. Society, nursing shortages, the healthcare industry’s need to provide save, quality health care while maintaining financial stability, and many other factors have shaped a path of opportunities for nurses today. Advanced Practice Nursing has been evolving to meet our society’s healthcare needs for decades. Nurses have been and will continue to be the driving force of these changes and our ability to manage change and move to a new conceptualization of advanced practice nursing will define our success or failure in meeting societal needs in the future (Denisco & Barker, 2013) Society and the healthcare industry have offered opportunities for recognition of and institutional credentialing of Advanced Practice Nurses...
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...Historical Development Matrix Complete the following matrix depicting the historical development of risk management and quality improvement. Select 8-10 historical regulatory and nonregulatory events and activities over the 20th century that contributed to the theoretical foundations of risk management. The matrix must identify the name, year, and founder of the development; the nature of the development; and its importance in the development of risk management and quality improvement. Use this table as a graphic organizer to summarize the theoretical underpinnings and historical development of risk management and quality improvement. Historical Development (Name, Year) Founder of Event Nature of Development Importance to Development of Risk Management and Quality Improvement 1. The National Health care Quality Report, 2011 Agency for Healthcare Research and Quality The nature of the development is to monitor and control nationally the quality of care in the United States. These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. In the 20th century new chapters on care coordination, health system infrastructures are put into place. The reports present, in chart form, the latest available findings on quality of and access to health care. According to Priority areas for national action: Transforming health care quality (2003), the committee decided a framework would be useful in helping to identify...
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...Quality Improvement Plan Part One—Consumerism HCS.588 Facilitator: Patricia Wolcott September 23, 2013 Quality Improvement Plan--Consumerism The Institute of Medicine’s widespread reports, To Err Is Human (2000) and Crossing the Quality Chasm, revealed widespread incidence of medical errors in U.S. hospitals, there has been a great deal of effort to measure and improve the quality of hospital care (Institute of Medicine, 2000). Progressive input have been made in establishing quality indicators and risk adjustment components to compare quality across organizations, and in analyzing processes and cultures in high-performing hospitals. There is a vast amount of knowledge to learn about the infrastructure of hospital performance. Health care organizations performance measures may include, which hospitals are improving (or deteriorating) over time and how they accomplish and provide for that improvement. This paper will seek to develop a quality improvement plan for St. Joseph Medical Center, the difference between performance measurement and quality improvement, examine quality indicators, and explain stakeholder feedback is used in the quality improvement process. Type of care Provided St. Joseph Medical Center has provided health care to the Kansas City metropolitan area since 1874. According to St. Joseph Medical Center (2013), “It is a joint accredited, 310-bed hospital offering a full array of acute care, outpatient and extended care services with a reputation for...
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...technology. There are samples of countries that display this ‘absolute convergence, however, such a phenomenon is not universal. These seemingly inexplicable variations in growth present an important question of what are the determinants and is there a role for stabilizing policy. Explain why the study is important. Why is economic growth so important? Coexistence of Growth miracles, Growth Disasters Barro (1991) provides that it is ultimately the relationship between the level of human capital and initial GDP that allows some poor countries to converge on rich countries. Ultimately, our conclusion parallels that of Barro’s and we find that the driving determinants of growth are Human capital, Investment and the initial GDP level. Our analysis follows the key ideas and assumptions of Barro’s model. We use both Primary and High School enrolment as a proxy for the accumulation of Human capital, however, this does pose some restrictions on our analysis. To examine this, a new index of human capital stock will be recommended. Most significantly… Summarise the findings of the paper. Our finding will ultimately accord with recent models such as Lucas [1988] and Romer [1990] that assume constant returns to reproducible capital. Although in these models the growth rate is independent of the starting GDP. We divorce...
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...Regulatory and Compliance: Hospital Communication and Wrong Site Surgery Prevention March 21st, 2014 Accreditation Audit Regulatory Audits and Compliance Hospital Communication and Wrong Site Surgery Prevention Background: Wrong Site Surgery is costly and horrifying experience for the patient, the physician and the hospital. It is considered a preventable medical error. In 1999, the Institue of Medicine report, To Err is Human states that “clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses because there was no process for recognizing, reporting, and tracking these events.” (LT Kohn, 2000) Physicians and nurses do not wake up desiring to harm patients, in fact, they take an oath to do not harm, but humans make mistakes. Unlike a mechanic or a car salesman, nurses and physicians are caring for people, and their mistakes can be detrimental to the patients to the point of death. The reasons safety nets need to be put into place to ensure compliance for the patient are obvious, but additionally for the physician and facility the cost of wrong site surgery (WSS) can be detrimental “State licensure boards are imposing penalties on surgeons for WSS, and some insurers have decided to no longer pay providers for WSS or wrong-person surgery, nor for leaving a foreign object in a patient’s body after surgery. Surgery performed on the wrong site or wrong person has also often been held compensable under malpractice claims. Seventy-nine...
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...and what's bad for you is wrong.” This phrase can be interpreted in a number of ways, the most popular one being: every person should act in their own self-interest. This means that when deciding on whether an action is good, any effect on others (mental or physical) by said action has no merit. An egoist that is measuring or justifying an action's goodness is only examining the possible positive or negative effects this action will have on him. The majority of the justification arguments for ethical egoism stems from both psychological egoism and rational egoism. Psychological egoism is the belief that all people, whether they believe so or not, always seek their own self-interest in actions and this behavior is unavoidable because it is human nature. Rational egoism is the similar belief that it is rational to do something in one's self interest and therefore...
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... Pay-for-Performance Emergence of Pay-for-Performance In 2000, the Institute of Medicine (IOM) released the report “To Err is Human: Building a Safer Health System.” The report catalyzed the attention of health care stakeholder groups in the nation (Stafford, 2000). The research provided a comprehensive, detailed account of health care errors and preventable deaths costing billions of unnecessary dollars in a health care system already spiraling out of control. The IOM recommended that Congress create a Center for Patient Safety within the Agency for Health Care Research and Quality for the purpose of designing a safer health care delivery system. Fifteen months after releasing the patient safety report, the IOM released “Crossing the Quality Chasm.” The report framed underlying reform necessary in the current health care delivery system to ensure patient safety. The framework sought to hold providers accountability for the quality of care they deliver. The introduction of the pay for performance (P4P) as opposed to the prior fee for service and prospective reimbursement guidelines induces delivery of care based upon performance measures. Broadly defined pay-for- performance includes any type of performance-based provider payment arrangements, including those that target performance on cost measures (U.S. Department of Health & Human Services, 2006) Reimbursement Pay-for-performance, synonymous with quality-based purchasing, bases reimbursement upon quality...
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...Changing the System Abstract The Affordable Care Act was signed into law in March of 2010 by President Obama, these set of new laws and regulations is designed to provide ethical changes to a fragmented health care system. Cultural bias and social stigmatism have hampered the acceptance of such sweeping changes to the American health care system. Culturally some Americans feel they are handing over their health care choices to government control, socially some Americans believe that the government it reducing free trade, taking control of health care and limiting capitalism in the health care market. This argument is to disprove those stances hoping to provide an outline of what Americans should accept as reasonable ethical, cultural and social changes to a system that was, and is, still fragmented in many ways. There have been many changes to the health care system thus far, but there are many more that need to take place. It is no longer ethically acceptable to just meet the medical needs of Americans, but to pursue greater levels of standards of care practices for those in need. Ethically it is time for Americans to start to question some of the cultural and social “norms” I believe and start to be more socially responsible for themselves and others regarding the health care system as a whole. By following this outline and looking at the examples I think that many Americans would agree that this would be an easy task to accomplish, it may take us as a society out...
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