6: Measuring safety
The critical role of measurement ‘You cannot manage what you cannot measure’ is a familiar and perhaps rather tired management mantra, but it certainly applies to improving safety and quality….
16: Procedures, violations and migrations
(GAWANDE, A. COMPLICATIONS. PROFILE BOOKS LTD, HOLT METROPOLITAN, 2002 AND PICADOR USA, APRIL 2003. REPRODUCED WITH PERMISSION) Although there is a certain amount of work in industry on safety behaviours…
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…
