Dedication i Preface ii Acknowledgements Introduction v Chapter 1. The language of (patient) safety - 1 - What is the difference between an adverse event and a patient safety incident? - 1 - Acronyms and Abbreviations - 7 - References - 9 - Chapter 2. A Brief History of Healthcare-associated Harm and Patient Safety - 11 - A timeline of patient safety in healthcare literature - 13 - References - 20 - Chapter 3. Modern Prevalence and Impact of Healthcare-Associated Harm - 23 - Overall prevalence of harm - 26 - Prevalence and type of healthcare-associated harm by medical setting and clinical specialty - 30 - Prevalence of harm from primary care medicine - 30 - Prevalence of harm from anaesthesia - 31 - Prevalence of harm from surgery - 32 - Prevalence of harm associated with diagnostic imaging - 33 - Laboratory medicine - 33 - Emergency care - 34 - Intensive care - 35 - Other medical specialties - 36 - How does this harm break down? - 36 - Medication error - 36 - Healthcare-associated infections - 37 - Misdiagnosis - 37 - Patient misidentification - 38 - Communication failure - 39 - What is the evidence for veterinary healthcare-associated harm? - 41 - Errors among veterinary new graduates - 42 - Errors in veterinary malpractice claims - 43 - A study of veterinary referral and emergency hospitals - 44 - Errors in corporate veterinary practices and hospitals in mainland Europe - 46 - Studies of complications associated with specific specialties - 47 - Studies of specific veterinary errors and healthcare-associated harms - 55 - Conclusion - 62 - References - 62 - Chapter 4. Why are patients harmed by healthcare? Theories, concepts and models - 73 - From simple linear causality models to complex non-linear models. - 75 - Are certain individuals just accident prone? - 77 - Simple linear models - 80 - Generalised Time Sequence Model - 81 - More advanced models - 84 - What is a system? - 85 - Normal Accident Theory - 88 - High Reliability Organisation theory - 93 - Normal Accident Theory versus High Reliability Organisations - 95 - Practical drift - 97 - Reason''s Organisational Accident and "Swiss Cheese" Models - 103 - Vincent et al.''s model of accidents in healthcare - 107 - Accidents as emergent properties of systems - 108 - Current approaches to safety - 110 - Systems Approaches - 110 - Human Factors Approaches - 113 - Resilience Engineering - 114 - Ways of envisioning and understanding working practices - 115 - Local rationality principle - 116 - Work-as-done versus Work-as-imagined - 116 - Efficiency-Thoroughness Trade-Off - 118 - The blunt-end and sharp-end of healthcare systems - 121 - Comparisons between Healthcare and Aviation - 122 - Comparisons of veterinary healthcare to other industries - 133 - The characteristics of working in veterinary medicine - 134 - Contrasting approaches to safety and risk management - 138 - What does this tell us about risk management in healthcare? - 139 - Why is patient safety so hard to improve? - 141 - Summary - 142 - References - 142 - Chapter 5. Human performance and error - 147 - What is an error? - 148 - Classification of human error - 149 - Violations - 152 - How we make decisions - 154 - Dual Process Theory - 154 - Rationality - 158 - Heuristics - 160 - Cognitive biases - 164 - Cognitive load and effort - 177 - Decision making styles - 179 - Decision making in clinical teams - 180 - Personality traits and affective state - 182 - Conclusions on decision-making - 184 - The effect of the social environment - 185 - Other important facets of human nature - 186 - What are Non-Technical Skills? - 187 - How do non-technical factors shape our performance - 188 - What are the different non-technical skills? - 189 - Situation awareness - 190 - Teamwork including Communication and Leadership - 197 - Task management - 218 - Personal self-management - 219 - Social and interpersonal management - 224 - When might human error be the most influential factor in an accident? - 228 - Failing to pay attention - 229 - Exceeding performance capabilities - 232 - Developing patterns of unsafe behaviour - 240 - Conclusion - 243 - References - 243 - Chapter 6.
Organisational, professional and safety cultures - 249 - What do the terms organisational, professional and safety culture mean? - 251 - Organisational Culture - 251 - Subcultures and cultural variations within organisations - 256 - Professional culture - 258 - What is Safety Culture? - 262 - Dimensions of Safety Culture - 263 - Themes in Safety Culture Identified in Healthcare - 272 - Other Key Principles Pertaining to Safety Culture - 274 - Psychological safety - 274 - Speaking Up is Hard to Do - 2.