Sukhmeet S. Panesar is Honorary Fellow, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK

Andrew 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, UK

Aziz 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 vii

Preface xi

Acknowledgements xii

How to use your revision guide xiii

Part 1 The essence of patient safety 1

1 Basics of patient safety 2
Kaveh G. Shojania and Sukhmeet S. Panesar

2 Understanding systems 4
Carl Macrae

3 Quality and safety 6
Ranjit Singh and Gurdev Singh

4 Human factors 8
Ken Catchpole

5 Teamwork and communication 12
Sukhmeet S. Panesar, Sarah A. Salvilla, Martin Bromiley and Jane Reid

6 Reporting and learning from errors 14
Tara Lamont

7 Research in patient safety 16
Lilly D. Engineer and Peter Pronovost

Part 2 Understanding and interpreting risk 19

8 Risk-based patient safety metrics 20
Elizabeth Allen and Sukhmeet S. Panesar

9 Root cause analysis 24
Donna Forsyth and Sundeep Thusu

10 Measuring safety culture 26
Debra de Silva

Part 3 Risks to patient care 31

11 Medication errors 32
Sarah P. Slight, Tony Avery and David W. Bates

12 Surgical errors 36
Sukhmeet S. Panesar, Bhupinder Mann, Rajan Madhok and Andrew Carson-Stevens

13 Diagnostic errors 40
Ashley N. D. Meyer, Velma L. Payne, Hardeep Singh and Mark L. Graber

14 Maternal and child health errors 44
Susan Leavitt Gullo and Pierre Barker

15 Slips, trips and falls 47
Susan Poulton and Frances Healey

16 Patient safety in paediatrics 50
Peter Lachman and Jane Runnacles

17 Technology in healthcare and e-iatrogenesis 54
Kathrin M. Cresswell

18 Nosocomial infections 58
Imran Qureshi and Sukhmeet S. Panesar

19 Mental health errors 60
Amar Shah and Kevin Cleary

20 Patient safety in primary care 64
Andrew Carson-Stevens and Adrian Edwards

Part 4 Quality improvement 67

21 Improving the quality of clinical care 68
Andrew Carson-Stevens and Maureen Bisognano

22 Science of improvement 70
Clifford Norman and C. Jane Norman

23 Model for Improvement 74
Clifford Norman and C. Jane Norman

24 Measurement for improvement 78
Mike Davidge

25 Spread and sustainability of improvement 84
Gareth Parry and Andrew Carson-Stevens

26 Quality improvement tools: visualisation 86
Ashley Kay Childers and David M. Neyens

27 Quality improvement: assessing the system 88
Ashley Kay Childers and David M. Neyens

28 Patient stories in improvement 90
Aled Jones and Andrew Carson-Stevens

29 Leading change in healthcare 92
Helen Bevan

30 Public narrative: story of self, us and now 96
Jay D. Bhatt and Andrew Carson-Stevens

31 Planning an improvement project 98
Lakshman Swamy and James Moses

32 Managing an improvement project 100
Valerie P. Pracilio

33 Quality improvement in psychiatry 104
Peter Klinger, Anthony Weiss and Eric Hazen

34 Quality improvement in intensive care 106
Kevin D. Rooney

35 Quality improvement in obstetrics 108
Gloria Esgebona

36 Quality improvement in surgery 110
Shabnam Hafiz

37 Population health and improvement 112
Mohammed Mustafa and Valerie P. Pracilio

Further reading 114

Index 121

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