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Contents

Contributors vii Preface xi Acknowledgements xii How to use your revision guide xiii Part 1 The essence of patient safety 1 1 Basics of patient safety 2 Kaveh G. Shojania and Sukhmeet S. Panesar 2 Understanding systems 4 Carl Macrae 3 Quality and safety 6 Ranjit Singh and Gurdev Singh 4 Human factors 8 Ken Catchpole 5 Teamwork and communication 12 Sukhmeet S. Panesar, Sarah A. Salvilla, Martin Bromiley and Jane Reid 6 Reporting and learning from errors 14 Tara Lamont 7 Research in patient safety 16 Lilly D. Engineer and Peter Pronovost Part 2 Understanding and interpreting risk 19 8 Risk-based patient safety metrics 20 Elizabeth Allen and Sukhmeet S. Panesar 9 Root cause analysis 24 Donna Forsyth and Sundeep Thusu 10 Measuring safety culture 26 Debra de Silva Part 3 Risks to patient care 31 11 Medication errors 32 Sarah P. Slight, Tony Avery and David W. Bates 12 Surgical errors 36 Sukhmeet S. Panesar, Bhupinder Mann, Rajan Madhok and Andrew Carson-Stevens 13 Diagnostic errors 40 Ashley N. D. Meyer, Velma L. Payne, Hardeep Singh and Mark L. Graber 14 Maternal and child health errors 44 Susan Leavitt Gullo and Pierre Barker 15 Slips, trips and falls 47 Susan Poulton and Frances Healey 16 Patient safety in paediatrics 50 Peter Lachman and Jane Runnacles 17 Technology in healthcare and e-iatrogenesis 54 Kathrin M. Cresswell 18 Nosocomial infections 58 Imran Qureshi and Sukhmeet S. Panesar 19 Mental health errors 60 Amar Shah and Kevin Cleary 20 Patient safety in primary care 64 Andrew Carson-Stevens and Adrian Edwards Part 4 Quality improvement 67 21 Improving the quality of clinical care 68 Andrew Carson-Stevens and Maureen Bisognano 22 Science of improvement 70 Clifford Norman and C. Jane Norman 23 Model for Improvement 74 Clifford Norman and C. Jane Norman 24 Measurement for improvement 78 Mike Davidge 25 Spread and sustainability of improvement 84 Gareth Parry and Andrew Carson-Stevens 26 Quality improvement tools: visualisation 86 Ashley Kay Childers and David M. Neyens 27 Quality improvement: assessing the system 88 Ashley Kay Childers and David M. Neyens 28 Patient stories in improvement 90 Aled Jones and Andrew Carson-Stevens 29 Leading change in healthcare 92 Helen Bevan 30 Public narrative: story of self, us and now 96 Jay D. Bhatt and Andrew Carson-Stevens 31 Planning an improvement project 98 Lakshman Swamy and James Moses 32 Managing an improvement project 100 Valerie P. Pracilio 33 Quality improvement in psychiatry 104 Peter Klinger, Anthony Weiss and Eric Hazen 34 Quality improvement in intensive care 106 Kevin D. Rooney 35 Quality improvement in obstetrics 108 Gloria Esgebona 36 Quality improvement in surgery 110 Shabnam Hafiz 37 Population health and improvement 112 Mohammed Mustafa and Valerie P. Pracilio Further reading 114 Index 121

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