Patient Safety, 2nd Edition

Preface ix

The nature of the book xi

Inspiration acknowledgements and thanks xiii

Section One The Evolution of Patient Safety

Chapter 1 Medical harm: a brief history 3

Chapter 2 The emergence of patient safety 14

Chapter 3 Integrating safety and quality 31

Section Two The Hazards of Healthcare

Chapter 4 The nature and scale of error and harm 49

Chapter 5 Reporting and learning systems 75

Chapter 6 Measuring safety 96

Section Three From Accident Analysis to System Design

Chapter 7 Human error and systems thinking 119

Chapter 8 Understanding how things go wrong 141

Section Four The Aftermath

Chapter 9 Caring for patients harmed by treatment 171

Chapter 10 Supporting staff after serious incidents 192

Section Five Design Technology and Standardization

Chapter 11 Clinical interventions and process improvement 211

Chapter 12 Design for patient safety 230

Chapter 13 Using information technology to reduce error 246

Section Six People Create Safety

Chapter 14 Creating a culture of safety 269

Chapter 15 Patient involvement in patient safety 290

Chapter 16 Procedures violations and migrations 307

Chapter 17 Safety skills 321

Chapter 18 Teams create safety 341

Section Seven The Journey to Safety

Chapter 19 Safe organizations: bringing it all together 371

Chapter 20 High performing healthcare systems 390

Index 405