Patient safety > Books
All books below are available for Trust staff to borrow from the Library Service. We can also order in other titles, free of charge. Please email bht.library@nhs.net
Implementing Patient Safety by
Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached. Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely. Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years. This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like. This book builds on the author's first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the 'how'. Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the author's personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.
Oops! Why Things Go Wrong by
"I am thirty miles south of London's Gatwick Airport, the world's busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails..."So begins this pioneering book by Niall Downey - a cardio-thoracic surgeon who retrained to become a commercial airline pilot - where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organization can greatly reduce the incidence and impact of making serious mistakes.While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring.An acknowledged expert in error management, Niall Downey advises governments, major corporations and the health industry on how to develop a systemic approach to controlling for human imperfection. Arguing that prevention is far preferable to denying responsibility after the fact, he gave an influential TEDx talk outlining how healthcare could use aviation's experience to reduce tragic outcomes and improve patient safety.
Oxford Professional Practice: Handbook of Patient Safety by
Every day, doctors are faced with the challenge of keeping the people they treat safe and free from harm. Patient safety is a relatively new field of study, but the field is expanding and there is now better understanding of what is needed to measure and achieve safety for patients.The Handbook of Patient Safety will empower doctors, nurses and other professionals to be able to develop safe clinical processes that allow proactive management and minimisation of risk, so that people are not harmed when they receive clinical care. It gives the rationale for patient safety, thetheories behind the science of patient safety and then the practical methods that frontline staff can use on a daily basis to decrease harm.Pocket sized and practical, this handbook is the ideal guide to support frontline staff and trainees, as well as all allied professionals in the name of patient safety. It reflects the World Health Organization's Patient Safety Curriculum and is written by international experts in their field whohave specialist interests and direct expertise in dealing with patient safety issues. This book will demystify what is often seen as a complex topic, helping doctors understand the methods needed to provide safe care.
Patient Safety by
The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting. Key features: Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) investigation, and how and when duty of candour applies Covers the technical aspects of serious incident recognition and report writing Includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports Offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow Explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical incidents are investigated and managed.
Patient Safety Now by
Over the past decade or so, we have seen a multitude of improvement programmes and projects to improve the safety of patient care in healthcare. However, the full potential of these efforts and especially those that seek to address an entire system has not yet been reached. The current pandemic has made this more evident than ever. We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic. If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological, and procedural boundaries. Patient Safety Now is about the fact that it is time to care for everyone impacted by patient safety, how we need to take the time to care for everyone in a meaningful way and how hospitals need to enable staff time to care safely. This book builds on the author's two previous books on patient safety. Rethinking Patient Safety talked about ways in which we need to rethink patient safety in healthcare and describes what we've learned over the last two decades. Implementing Patient Safety talked about what we can do differently and how we can use those lessons learned to improve the way we implement patient safety initiatives and encourage a culture of safety across a healthcare system. Patient Safety Now unites the concepts, theories and ideas of the previous two books with updated material and examples, including what has been learned by patient safety specialists during a pandemic. Patient Safety Now provides the reader with a unique view of patient safety that looks beyond the traditional negative and retrospective approach to one that is proactive and recognizes the impact of conditions, behaviours and cultures that exist in healthcare on everyone. It is written not only for healthcare professionals and patient safety personnel, but for patients and their families who all want the same thing. Too often when things go wrong, relationships quickly become adversarial when in fact this can be avoided by recognizing that, rather than being in separate camps, there are shared needs and goals in relations to patient safety.
Why Mothers Died and How Their Lives Are Saved by
One of the most dramatic changes to women's lives in the twentieth century was the advent of safe childbirth, reducing the maternal mortality rate from 1 in 400 births to 1 in 10,000 in just 80 years. The impetus behind this change was the Confidential Enquiries into Maternal Death (CEMD), now the world's longest running self-audit of a healthcare service. Here, leading authors in the CEMD tell the story of the pioneering clinicians behind the push for improvements, who received little recognition for their work despite its far-reaching consequences. One by one, the leading causes of maternal death were identified and resolved, from sepsis to safe abortions and more recently psychiatric illness and social and ethnic disparities in healthcare. Global maternal mortality is still too high; this valuable book shows how significant advances in maternal healthcare are possible when clinicians, politicians and the public work together.
Listening for What Matters by 
Zero: Eliminating Unnecessary Deaths in a Post-Pandemic NHS by 
Safety-I and Safety-II by
Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from 'avoiding that something goes wrong' to 'ensuring that everything goes right'. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoret
Root Cause Analysis and Improvement in the Healthcare Sector by 
Human Factors in Healthcare by
The majority of errors, litigation, and complaints in the health service are due to "human factors", yet the term is still not widely understood and is sometimes used interchangeably to refer to team training or communication skills. Although including these, the subject of "human factors"goes far beyond this to look at systems, environmental influences, and interactions with equipment, in addition to self-awareness and human interaction. All of these aspects are captured in Human Factors in Healthcare and are built into a new framework: the SHEEP model, which breaks down into fivekey areas: Systems, Human Interaction, Environment, Equipment, and Personal, providing a structured way to focus on adopting "safety positive" behaviours.Written in a clear and engaging way, the book is ideal for clinicians and non-clinicians alike. Through the use of relevant real world healthcare examples and exercises the book encourages interaction and thinking, as well as illustrating how mistakes can be avoided. The book also sets out ways onhow to improve the experience of patients and staff across healthcare, in particular focusing on how to improve patient safety. In light of regular news reports about patient care, Human Factors in Healthcare presents a timely and proactive approach to these issues and is essential reading fordoctors, nurses, managers, and everyone working in the healthcare profession.
Human Factors in Healthcare: Level Two by
Building on Level One, this volume of iHuman Factors in Healthcare/i continues to enhance and develop the SHEEP model, delving deeper into the challenges of leadership, conflict resolution, and decision making that healthcare professionals currently face.Presenting the five components of the SHEEP framework; Systems, Human Interaction, Environment, Equipment, and Personal, this book allows readers to develop their own human factors based approach within their workplace. Through a wealth of real-life examples of errors and patient safety issues drawnfrom the author's experience from over twenty years in healthcare, it enables the identification of potential patient safety pitfalls and offers solutions on how to avoid them.Written in a clear and engaging style, this is a valuable resource for guiding healthcare professionals including doctors and nurses through the requirements of the human factors-based approach to leadership, conflict resolution, and decision making.See also: iHuman Factors in Healthcare: Level One/i 978-0-19-967060-4
Problem Solving for Healthcare Workers by
While most healthcare facilities have an extremely high success rate at the most challenging lifesaving work and we all know of friends and relatives who have had supreme care, mistakes are still made and patients' lives have been put at risk and lost. How often have we heard politicians say after some disastrous report, "Lessons must be learned", but what does this really mean. Will responsible parties carry out a careful cause and effect analysis and methodically get to the root causes of the problem? Will sufficient steps be taken to permanently eradicate those causes and provide a permanent solution so that the problem will not reoccur? This is what is done in the aviation industry with the result that air travel is very safe. The low accident rate is achieved by studying the causes and using the methods of continuous improvement explained in this book. These methods are now becoming better known in the medical profession have been recommended in recent reports but are perhaps misunderstood at operational levels. This book is a basic level manual for those who have never been involved in any form of quality improvement project and is also suitable as a refresher for anyone wishing to familiarize themselves with the various techniques discussed. The aim of this book is to explain what continuous improvement is and why it's needed; explain how individual departments can explain how and why continuous improvement is important, and helps readers recognize quality control methods in their own workplace and understand how to contribute to existing continuous improvement activities. While many of the case studies and examples are from the NHS, the author includes similar examples from around the world.
The Field Guide to Understanding 'Human Error' by
When faced with a 'human error' problem, you may be tempted to ask 'Why didn't these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it. Building on its successful predecessors, the third edition of The Field Guide to Understanding 'Human Error' will help you understand a new way of dealing with a perceived 'human error' problem in your organization. It will help you trace how your organization juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organization, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand how to move beyond 'human error'; how to understand accidents; how to do better investigations; how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organization face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organization. If you are faced with a 'human error' problem, abandon the fallacy of a quick fix. Read this book.
Root Cause Analysis (RCA) for the Improvement of Healthcare Systems and Patient Safety by
The book follows a proven training outline, including real-life examples and exercises, to teach healthcare professionals and students how to lead effective and successful Root Cause Analysis (RCA) to eliminate patient harm. This book discusses the need for RCA in the healthcare sector, providing practical advice for its facilitation. It addresses when to use RCA, how to create effective RCA action plans, and how to prevent common RCA failures. An RCA training curriculum is also included. This book is intended for those leading RCAs of patient harm events, leaders, students, and patient safety advocates who are interested in gaining more knowledge about RCA in healthcare.
Black box thinking: marginal gains and secrets of high performance by 
Joshua's story: uncovering the Morecambe Bay NHS scandal by 
