Patient Safety and Healthcare Improvement at a Glance

Sukhmeet S. Panesar is Honorary Fellow, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UKAndrew Carson-Stevens is Clinical Lecturer in Healthcare Improvement, Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, UK Sarah A. Salvilla is Honorary Fellow, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UKAziz Sheikh is Professor of Primary Care Research and Development, Co-Director of Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK; Visiting Professor of Medicine, Harvard Medical School, Harkness Fellow in Health Policy and Practice, Brigham and Women's Hospital, Harvard Medical School, Boston, USA

• Contributors viiPreface xiAcknowledgements xiiHow to use your revision guide xiiiPart 1 The essence of patient safety 11 Basics of patient safety 2Kaveh G. Shojania and Sukhmeet S. Panesar2 Understanding systems 4Carl Macrae3 Quality and safety 6Ranjit Singh and Gurdev Singh4 Human factors 8Ken Catchpole5 Teamwork and communication 12Sukhmeet S. Panesar, Sarah A. Salvilla, Martin Bromiley and Jane Reid6 Reporting and learning from errors 14Tara Lamont7 Research in patient safety 16Lilly D. Engineer and Peter PronovostPart 2 Understanding and interpreting risk 198 Risk-based patient safety metrics 20Elizabeth Allen and Sukhmeet S. Panesar9 Root cause analysis 24Donna Forsyth and Sundeep Thusu10 Measuring safety culture 26Debra de SilvaPart 3 Risks to patient care 3111 Medication errors 32Sarah P. Slight, Tony Avery and David W. Bates12 Surgical errors 36Sukhmeet S. Panesar, Bhupinder Mann, Rajan Madhok and Andrew Carson-Stevens13 Diagnostic errors 40Ashley N. D. Meyer, Velma L. Payne, Hardeep Singh and Mark L. Graber14 Maternal and child health errors 44Susan Leavitt Gullo and Pierre Barker15 Slips, trips and falls 47Susan Poulton and Frances Healey16 Patient safety in paediatrics 50Peter Lachman and Jane Runnacles17 Technology in healthcare and e-iatrogenesis 54Kathrin M. Cresswell18 Nosocomial infections 58Imran Qureshi and Sukhmeet S. Panesar19 Mental health errors 60Amar Shah and Kevin Cleary20 Patient safety in primary care 64Andrew Carson-Stevens and Adrian EdwardsPart 4 Quality improvement 6721 Improving the quality of clinical care 68Andrew Carson-Stevens and Maureen Bisognano22 Science of improvement 70Clifford Norman and C. Jane Norman23 Model for Improvement 74Clifford Norman and C. Jane Norman24 Measurement for improvement 78Mike Davidge25 Spread and sustainability of improvement 84Gareth Parry and Andrew Carson-Stevens26 Quality improvement tools: visualisation 86Ashley Kay Childers and David M. Neyens27 Quality improvement: assessing the system 88Ashley Kay Childers and David M. Neyens28 Patient stories in improvement 90Aled Jones and Andrew Carson-Stevens29 Leading change in healthcare 92Helen Bevan30 Public narrative: story of self, us and now 96Jay D. Bhatt and Andrew Carson-Stevens31 Planning an improvement project 98Lakshman Swamy and James Moses32 Managing an improvement project 100Valerie P. Pracilio33 Quality improvement in psychiatry 104Peter Klinger, Anthony Weiss and Eric Hazen34 Quality improvement in intensive care 106Kevin D. Rooney35 Quality improvement in obstetrics 108Gloria Esgebona36 Quality improvement in surgery 110Shabnam Hafiz37 Population health and improvement 112Mohammed Mustafa and Valerie P. PracilioFurther reading 114Index 121

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