Contents
Preface ii
Acknowledgements
Introduction v
Chapter 1. The language of (patient) safety 1
Chapter 2. A Brief History of Healthcare associated Harm and Patient Safety 11
Chapter 3. Modern Prevalence and Impact of Healthcare Associated Harm 23
Chapter 4. Why are patients harmed by healthcare? Theories, concepts and models 73
Chapter 5. Human performance and error; 147
Chapter 6. Organisational, professional and safety cultures; 249
Chapter 7. Dealing with the nonclinical aftermath of an incident or error; 311
Chapter 8. Methods of assessment and measurement in patient safety 356
Chapter 9. Analysis Techniques for Patient Safety Investigations 568
Chapter 10. Patient Safety Interventions 713
Chapter 11. Feedback and closing the loop: Quality Improvement Cycles 890
Chapter 12. Ethics in Patient Safety Investigations; 902
Chapter 13. Suggested unified approach for veterinary healthcare; 940
Appendix I. Glossary of terms; 980
Appendix II: List of veterinary clinical practice guidelines 989
Anesthesia and Analgesia; 989
Emergency and Critical Care (including transfusion medicine) 991
Cardiology; 992
Dentistry; 993
Dermatology 994
Internal medicine; 996
Neurology; 1011
Oncology; 1012
General practice; 1012
Equine; 1017
Appendix III. Case studies; 1023
Case Study 1: Improving Compliance with a Checklist 1023
Situation 1023
Background; 1023
Assessment & Analysis; 1024
Recommendations 1025
Case study 2: Improving Reliability and Safety in an Intensive Care Unit 1027
Situation 1027
Background; 1027
Assessment & Analysis; 1028
Recommendations 1029
Case study 3: Improving the Safety of Infused Medications 1032
Situation 1032
Background; 1032
Assessment & Analysis; 1033
Recommendations 1034
Case Study 4: Introducing an Incident Reporting System 1037
Situation 1037
Background; 1037
Assessment & Analysis; 1039
Recommendations 1041
Case study 5: Improving the Safety of Overnight Care 1043
Situation 1043
Background; 1043
Assessment & Analysis; 1044
Recommendations 1047
Case Study 6: Reducing Wound Complications and Surgical Site Infections 1049
Situation 1049
Background; 1049
Assessment & Analysis; 1052
Recommendations 1053
