Adverse events occur in healthcare with worrying and surprising frequency and, of these, a substantial portion are preventable. This highly-readable book, translated and update from the original Dutch edition, presents 15 model case studies which have been carefully designed to explore common themes in medical errors and offer learnings from those events that will guide practice to prevent similar tragedies unfolding in future. Using 15 years of experience working in patient safety, the author makes concrete recommendations around assessment, attitude and performance, and provides a concise and accessible methodology for working safely.
Table of Contents
Chapter 1 – Worst Case Scenario
Chapter 2 – your own observation is flawed
Chapter 3 – Assumption is the mother of all screw-ups
Chapter 4 – be prepared
Chapter 5 – Speak up
Chapter 6 – What am I missing here?
Chapter 7 – Nine Red Flags
Chapter 8 – HALT
Chapter 9 – Photo or film
Chapter 10 – Risk accumulation
Chapter 11 – Just Culture
Chapter 12 – Blind faith
Chapter 13 – Bias
Chapter 14 – Professional performance
Chapter 15 – Open Disclosure
Chapter 16 – Epilogue
Chapter 17 – Summary
Ian Leistikow is a non-practicing physician. He was the coordinator of the patient safety program within the University Medical Center Utrecht, the Netherlands, from 2003 to 2011. This program comprised for example the introduction of Root Cause Analysis (RCA), proactive risk analysis (HFMEA), research on handoffs, research on patient participation and a video game on patient safety (www.airmedicsky1.org). He has set up various patient safety related trainings, has published multiple articles about patient safety and is co-author on a book about RCA. In December 2011 he published his PhD thesis on how the Board of Directors can lead patient safety improvements. His thesis is condensed into an article which was published in BMJ in July 2011. In 2014 he published a Dutch book on learning from Sentinel Events, which was widely recognized in the Netherlands. Since April 2011 Ian works as senior inspector at the Dutch Healthcare Inspectorate. There his tasks include judging the quality of sentinel event analysis reports from hospitals and coordinating the Dutch national set of quality indicators for hospitals. Ian is member of the Strategic Advisory Board of the International Forum on Quality and Safety in Healthcare. He is also one of the initiators of GetUpGetBetter (www.getupgetbetter.com), a series of international healthcare quality competitions, that is currently being developed.