Patient Safety. John Sandars Senior Lecturer in Community Based Education Medical Academic Education Unit, University of Leeds, Leeds, UK

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1 Patient Safety

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3 Patient Safety EDITED BY John Sandars Senior Lecturer in Community Based Education Medical Academic Education Unit, University of Leeds, Leeds, UK Gary Cook Consultant Epidemiologist, Stepping Hill Hospital Stockport NHS Foundation Trust, Stockport, UK Honorary Senior Fellow in Public Health University of Manchester, Manchester, UK

4 2007 by Blackwell Publishing Ltd Chapter 9 Michael Jones (and Gary Cook) BMJ Books is an imprint of the BMJ Publishing Group Limited, used under licence Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts , USA Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of this Work has been asserted in accordance with the Copyright, Designs and Patents Act All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. First published Library of Congress Cataloging-in-Publication Data ABC of patient safety / edited by John Sandars and Gary Cook. p. ; cm. Includes bibliographical references. ISBN Hospital care--safety measures. 2. Hospital care--quality control. I. Sandars, John, MB. II. Cook, Gary, [DNLM: 1. Patient Care--standards. 2. Medical Errors--prevention & control. 3. Safety Management--methods. W 84.1 A ] RA972.A '9--dc22 ISBN: A catalogue record for this title is available from the British Library Cover image of handwashing by a member of hospital staff is courtesy of John Cole/ Science Photo Library Set in Minion 9.25/12pt by Sparks, Oxford Printed and bound in Singapore by Fabulous Printers Pte Ltd Associate Editor: Vicki Donald Editorial Assistant: Victoria Pittman Production Controller: Rachel Edwards For further information on Blackwell Publishing, visit our website: The publisher s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book.

5 Contents Contributors, vii Preface, ix 1 The Scope of the Problem, 1 John Sandars 2 The Nature of Error, 4 Jenny Firth-Cozens, John Sandars 3 Diagnosis, 9 John Sandars 4 Use of Medication, 12 Darren M Ashcroft, Judith A Cantrill 5 Communication and Patient Safety, 16 Martin Beyer, Julia Rohe, Peter J Nicklin, Keith Haynes 6 Patient Safety Culture, 20 Tanya Claridge, John Sandars 7 Principles of Clinical Risk Management, 24 Julie Price, Peter J Nicklin, Keith Haynes 8 Learning from Threats to Patient Safety, 29 Maureen Baker, Richard Thomson, John Sandars 9 Patient Safety and the Law, 34 Michael Jones, Gary Cook 10 The Healthcare Policy Context, 37 Robert L Phillips 11 The Impact on Patients and Healthcare Professionals, 41 Amanda Howe, Peter Walsh 12 Future Directions, 44 Aziz Sheikh, Maureen Baker, Richard Thomson Index, 47 v

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7 Contributors Darren M Ashcroft Clinical Senior Lecturer, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK Maureen Baker Special Clinical Adviser, National Patient Safety Agency, London, UK Martin Beyer Senior Researcher in Quality Improvement and Patient Safety, Institute for General Practice, Frankfurt, Germany Judith A Cantrill Professor of Medicines (Usage, Evaluation and Policy), School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester, UK Tanya Claridge Professional Development Advisor and Health Visitor, Stockport Primary Care Trust, Stockport, UK Jenny Firth-Cozens Special Adviser on Modernisation of Postgraduate Education, London Deanery, London, UK Keith Haynes Director, MPS Risk Consulting Ltd, Leeds, UK Amanda Howe Professor of Primary Care, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK Michael Jones Professor of Common Law, University of Liverpool, Liverpool, UK Peter J Nicklin Associate Consultant with the Medical Protection Society and Honorary Senior Lecturer at the University of Leeds Medical School, UK Robert L Phillips Director of the Robert Graham Centre for Policy Studies in Family Medicine and Primary Care, The Robert Graham Centre, Washington DC, USA Julie Price Clinical Risk Manager, MPS Risk Consulting Ltd, Leeds, UK Julie Rohe Research Scientist, Agency for Quality in Medicine, Berlin, Germany Aziz Sheikh Professor of Primary Care Research and Development, Division of Community Health Sciences, University of Edinburgh, UK Richard Thomson Director of Epidemiology and Research, National Patient Safety Agency, London, UK; Professor of Epidemiology and Public Health, Institute of Health Sciences, Newcastle University, Newcastle upon Tyne, UK Peter Walsh Chief Executive, Action Against Medical Accidents, Croydon, UK vii