15 Human factors, patient safety and quality improvement
CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT
CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT tients Clinical audit, a function of clinical governanc...
COMMUNICATION Professional behaviour and maintaining fitness to practice
COMMUNICATION Professional behaviour and maintaining fitness to practice Professionalism is an imp...
Checklists
Checklists Checklists in the operating theatre environment are now accepted as standard safety pr...
Clinical microsystems
Clinical microsystems A clinical microsystem is an interdependent quality improvement unit made u...
Communicating openly with patients and their carers and obtaining consent
Communicating openly with patients and their carers and obtaining consent A patient-centred appro...
HUMAN FACTORS
HUMAN FACTORS The healthcare setting has become increasingly complex. Patient and societal demand...
Hospital level
Hospital level Clinical governance Patient safety requires a team approach. Many national and int...
INCIDENTS
INCIDENTS Understanding the concepts underlying patient safety inci - dents is useful because it ...
International
International Since 2009, WHO has embarked on a series of global and regional initiatives to imp...
Introduction
INTRODUCTION In recent years, increased emphasis has been placed on the study of healthcare syst...
Lean
Lean Lean improvement methodologies originated in industrial settings among frontline workers and...
Learning objectives
Learning objectives To learn: The importance of understanding human behaviour, • quality and valu...
Low- and middle-income countries
Low- and middle-income countries Resource-poor countries share many of the aspirations and chall...
Model for improvement
Model for improvement Based on the teachings of W . Edwards Deming ( Table 15.4 ), the model for...
Never events
Never events Many national health services and institutions now require that all incidents are ma...
PATIENT SAFETY AND RISK MANAGEMENT
PATIENT SAFETY AND RISK MANAGEMENT Patient safety can only be considered in a broader understand ...
PATIENT SAFETY AND THE SURGEON PROFESSIONAL RESPONSIBILITY
PATIENT SAFETY AND THE SURGEON: PROFESSIONAL RESPONSIBILITY Among medical specialties, surgery is...
PATIENT SAFETY
PATIENT SAFETY Medicine will never be risk-free. From the beginning of train - ing, doctors are ...
Prescribing safely
Prescribing safely Patients are vulnerable to mistakes made in any one of the many steps involve...
QUALITY MEASURES
QUALITY MEASURES Measurement is a key principle of quality improvement. Although many changes ta...
Resource-rich countries
Resource-rich countries Many countries and professional bodies in resource-rich coun - tries have...
STRATEGIES FOR PATIENT SAFETY
STRATEGIES FOR PATIENT SAFETY As safety is everybody’s business, building and embedding a safety ...
Shouldering the burden of adverse event
Shouldering the burden of adverse event As primary care givers and clinical leaders, surgeons wil...
Situation awareness identifying
Situation awareness: identifying
Situational awareness understanding the work environment and working well within it
Situational awareness: understanding the work environment and working well within it Nowhere is t...
Six Sigma
Six Sigma Six Sigma refers to another business performance meth odology that has been adopted for...
Supporting a safety culture
Supporting a safety culture Adverse events and near misses go unreported for many reasons, includ...
Surgical Safety Checklist
Surgical Safety Checklist B efore induction of anaesthesia B efore skin incision (with nurse, ana...
Systems thinking and leadership
Systems thinking and leadership In a system as complex as health care, ‘systems’ thinking allows ...
THE PROCESS OF SURGICAL CARE
THE PROCESS OF SURGICAL CARE Patients attend surgeons in many di ff erent settings depending on w...
THE QUALITY IMPROVEMENT PATHWAY
THE QUALITY IMPROVEMENT PATHWAY Quality improvement can be applied to almost any step, process or...
Technical and operative errors
Technical and operative errors In surgery , the person rather than systems approach empha - sises...
The person approach
The person approach Human performance principles tell us that humans are fallible and that errors...
The system approach
The system approach Health systems add complex organisational structures to human fallibility , t...
UNDERSTANDING PATIENT SAFETY
UNDERSTANDING PATIENT SAFETY
When things go wrong open disclosure
When things go wrong: open disclosure Communicating honestly with patients after an adverse event...
teamwork errors
teamwork errors Operating theatres have been described as ‘among the most - complex political, so...