2nd Edition
Patient Safety Investigating and Reporting Serious Clinical Incidents
About the Author
1. Introduction: Why do we still miss appendicitis?
2. Clinical incident investigation: Background and context
3. How do we recognise patient safety incidents that need in-depth investigation?
4. Recognising serious patient safety incidents using the SIRT: Case studies
5. A culture of complaint: Openness, candour and blame
6. RCA: Understanding what happened
7. RCA: Understanding how
8. RCA: Understanding why
9. Understanding why: System factors
10. Understanding why: Human error, Part 1
11. Understanding why: Human error, Part 2: Situational awareness and high-pressure environments
12. Root cause
13. Learning and recommendations
14. Solution design and changing cultures
15. Writing reports
Glossary
Index
Biography
Dr Russell Kelsey is a GP and independent investigator of serious clinical incidents. He has developed a highly successful and popular CPD accredited training course on SI recognition and Root Cause Analysis investigation.
