12: Design for patient safety
(REILING, 2006) BOX 12.1 The psychopathology of everyday things ‘The human mind is exquisitely tailored to make sense of the world. Give it the slightest clue and off it goes,…
13: Using information technology to reduce error
The limits of memory The sheer quantity of medical information, even within a single speciality, is often beyond the power of one person to comprehend. People, that is, the human…
20: High performing healthcare systems
Conditions and drivers of change We have already reviewed the conditions that provide the necessary foundations for change in clinical microsystems. The transformation of an entire health economy requires that…
14: Creating a culture of safety
LEAPE ET AL. (1998) A somewhat lethal cocktail of impatience, scientific ignorance and naive optimism may have dangerously inflated our expectations of safety culture.(COX AND FLIN, 1998) Both these statements…
3: Integrating safety and quality
Defining patient safety Patient safety can, at its simplest, be defined as: The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.(VINCENT, 2006) This…
15: Patient involvement in patient safety
(ADAPTED FROM BERWICK DM. “TAKING ACTION TO IMPROVE SAFETY: HOW TO IMPROVE THE CHANCES OF SUCCESS.” PRESENTATION AT THE ANNENBERG CENTER FOR HEALTH SCIENCES CONFERENCE, ENHANCING PATIENT SAFETY AND REDUCING…
11: Clinical interventions and process improvement
(BERWICK DM. ‘‘TAKING ACTION TO IMPROVE SAFETY: HOW TO IMPROVE THE CHANCES OF SUCCESS.’’ PRESENTATION AT THE ANNENBERG CENTER FOR HEALTH SCIENCES CONFERENCE, ENHANCING PATIENT SAFETY AND REDUCING ERRORS IN…
10: Supporting staff after serious incidents
(GAWANDE, 2002) BOX 10.1 Death of a child When I was an inexperienced registrar some eight years ago, a child died under my care. Her death was largely preventable, but…
9: Caring for patients harmed by treatment
(ADAPTED FROM VINCENT, 2001) Mrs Long suffered a series of avoidable surgical complications over a period of several months which left her in considerable pain. Traumatic experiences, chronic pain and…
1: Medical harm: a brief history
The cure can be worse than the disease Medicine has always been an inherently risky enterprise, the hopes of benefit and cure always linked to the possibility of harm. The…
