4: The nature and scale of error and harm
Studying errors and adverse events There are a number of methods of studying errors and adverse events, each of which has evolved over time and been adapted to different contexts….
18: Teams create safety
What is a team? A team in a formal sense is a group of individuals with a shared, common goal who, while they each have defined individual tasks, achieve their…
19: Safe organizations: bringing it all together
Clinical microsystems A clinical microsystem is a group of clinicians and staff working together with a shared clinical purpose to provide care for a defined population of patients (Mohr, Batalden…
8: Understanding how things go wrong
(TOFT, 2001) Following an Internal Enquiry at QMC, Professor Brian Toft was commissioned by the Chief Medical Officer of England to conduct an enquiry into the death and to advise…
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…
