1st Edition

Prevention is Better than Cure Learning from Adverse Events in Healthcare

By Ian Leistikow Copyright 2017
    136 Pages 3 B/W Illustrations
    by CRC Press

    136 Pages 3 B/W Illustrations
    by CRC Press

    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.


    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.