The Patient Safety Handbook.  Edited by Barbara J. Youngberg and Martin J. Hatlie. Jones and Bartlett Publishers, 2004. ISBN: 0763731471. 779 pages. Price: $99.95.

A strong interest in patient safety arose from the oft-cited 1999 Institute of Medicine report “To Err is Human.”1Enough has happened in the ensuing 5 yr to provide information for compilation into a handbook that would be useful to those engaged in or entering this new discipline. Unfortunately, this book does not fulfill that need. Although there are some good chapters, the overall product is not good enough to warrant a “buy” recommendation. Moreover, it pays little attention to the pioneering work in anesthesia and all that work offers for the education of others. That is but one of the book’s shortcomings.

First, this is certainly not a handbook. A better title would have been “A Collection of Essays on Patient Safety.” A handbook should at least attempt to be comprehensive about information pertinent to the field. Few chapters even come close. For example, when a chapter presents some specific information for application in a patient safety topic, it typically describes only one approach, the one known to or developed by the chapter author(s). Also, data, techniques, and tools are not in an accessible format, as would be expected of a “handbook.” For example, how could a handbook on safety not have even a table of definitions given the importance of consistent terminology (which is often lacking)? A list of websites for patient safety information would also have been useful.

The organization of the book is lacking. The editors give us no overview or introduction to the topic of patient safety. There is no attempt to guide the reader on how to use the book or “roadmap” of its organization. The chapter order seems to be random. How else to explain why chapter 8 on incident investigation and Chapter 16 on root cause analysis are separated by completely disparate topics? Chapters 24 and 25 on the subject of teamwork are adjacent, but chapter 22 is also mostly about teamwork while Chapter 23 is “Engaging the Board of Directors.” The paucity of references is one obvious measure of how poorly most topics are researched. There are relatively few references in the majority of chapters; several chapters have none. Every conceivable style of reference is used. This is just one of many indications of the lack of coordination. It is common for multi-authored texts to be inconsistent, but I found this text to be especially disjointed and disconnected.

The opening chapters are passable reviews of the two Institute of Medicine reports most applicable to patient safety. But, remarkably, there is no connection made between them. Nor is there any attempt to differentiate between quality and safety, which is a fundamental question for those involved in patient safety. This demonstrates a lack of understanding of the larger issues and the general failure of this book to provide meaningful new insights. As an example, Chapter 3 discusses “Interpersonal Relationships: The Soft Stuff of Patient Safety.” Ostensibly it addresses organizational culture, but it refers to almost none of the important literature or concepts. Five of the 12 references are the author’s own; one is a novel. Only one tool for measuring culture characteristics is mentioned (it is actually useful and web accessible, but you have to go find it yourself because it is not referenced—the author gives his email address for those who seek more information, but it was easy to find the survey via  a web search). There is a glaring error on page 38 in representing a paper that actually concerns communication in intensive care units,2whereas the author states that it refers to emergency departments.

Many other chapters are problematic. The chapter concerning organizational culture is woefully inadequate. The only presentation of useful tools and techniques is three paragraphs under a “guide to senior leaders.” The two references are from 1951 and 1987. This is certainly not sufficient for a handbook and unacceptable even for an essay. The chapter on incident reporting and investigation describes “the investigation process” as if there were only one available technique. The material presented is a good overview and useful for the neophyte but is insufficient for the scope of a topical handbook. That no reference is made between this chapter and the one on “Root Cause Analysis” is further evidence for points noted above regarding the lack of coordination. Other chapters seem to miss the bulk of information on their purported topic.

I could continue the critique, but I think the case has been made for my overall assessment. Yet there are some high points. The chapter by Julianne Morath, R.N., M.S. (Chief Operating Officer, The Children’s Hospital and Clinics of the Twin Cities, Minneapolis, Minnesota), is well presented and a useful guide to the leaders and managers who want to undertake organizational change. Roxanne Goeltz, an air traffic controller from Minneapolis, Minnesota, is a crusader who came to safety after the untimely iatrogenic death of her brother. She writes a compelling set of stories of her experiences in the world of healthcare mismanagement. It should be required reading for medical students and their teachers. The chapter on epidemiology is a good primer on the topic. One chapter on systematic approaches to dealing with medication errors is also relatively thorough and practical. I learned things from the chapter by Karin Lindgren (General Counsel, University HealthSystem Consortium, Oak Brook, Illinois) entitled “The Criminalization of Health Care: When is Medical Malpractice a Crime?” In addition to the interesting case reviews, there is good practical advice for risk managers on handling a pending criminal investigation.

The sparse reference to anesthesia leadership in patient safety and the almost complete lack of useful information for anesthesia clinicians is reason enough not to recommend this book to the readers of Anesthesiology. Yes, the work of the Anesthesia Patient Safety Foundation (Indianapolis, IN) is praised in three places. Unfortunately, in one, the historical facts are wrong. The “20/20” television segment did not directly “spur” the formation of the Anesthesia Patient Safety Foundation (it did “spur” immediate interest in oxygen analyzers and “enabled” efforts to form the Anesthesia Patient Safety Foundation, which was spurred more by other forces). Also, the Anesthesia Patient Safety Foundation did not develop anesthesia practice standards (one more example of misinterpretation of the literature). And, among 44 chapters and 779 pages, one would have expected much more about the pioneering role of anesthesia and at least a reference to the large body of literature and the many interventions made. At least one would expect to find mention of Ellison C. Pierce, Jr., M.D., founder and first president of the Anesthesia Patient Safety Foundation, later its executive director and the first pioneering patient safety leader. His name does not appear in the index, although at least half of the names indexed are of people who made little or no contributions to patient safety. Given that there is a chapter on the work of the Institute for Safety Medication Practice (Huntingdon Valley, PA), a chapter on anesthesia would have been warranted.

People who are new to the field of patient safety need a good place to start, but unfortunately this book is not it. Perhaps, given the dearth of overviews on the topic, it might be useful for an undergraduate class on patient safety if a few chapters were selected. However, if I were the teacher, I would use a collection of original articles.

Partners HealthCare System, Inc., Harvard Medical School, and Massachusetts General Hospital, Boston, Massachusetts.

Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press, 1999
Washington DC
National Academy Press
Knaus W, Draper EA, Wagner DP, Zimmerman JE An evaluation of outcome from intensive care in major medical centers. Ann Intern Med 1986; 104:410–8