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Checklists Checklists in the operating theatre environment are now accepted as standard safety pr...

Clinical microsystems A clinical microsystem is an interdependent quality improvement unit made u...

Communicating openly with patients and their carers and obtaining consent A patient-centred appro...

CLINICAL OUTCOMES, AUDIT AND IMPROVEMENT tients Clinical audit, a function of clinical governanc...

COMMUNICATION Professional behaviour and maintaining fitness to practice Professionalism is an imp...

teamwork errors Operating theatres have been described as ‘among the most - complex political, so...

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 Communicating honestly with patients after an adverse event...

THE QUALITY IMPROVEMENT PATHWAY Quality improvement can be applied to almost any step, process or...

Technical and operative errors In surgery , the person rather than systems approach empha - sises...

The person approach Human performance principles tell us that humans are fallible and that errors...

Surgical Safety Checklist B efore induction of anaesthesia B efore skin incision (with nurse, ana...

Systems thinking and leadership In a system as complex as health care, ‘systems’ thinking allows ...

THE PROCESS OF SURGICAL CARE Patients attend surgeons in many di ff erent settings depending on w...

Situational awareness: understanding the work environment and working well within it Nowhere is t...

Six Sigma Six Sigma refers to another business performance meth odology that has been adopted for...

Supporting a safety culture Adverse events and near misses go unreported for many reasons, includ...

STRATEGIES FOR PATIENT SAFETY As safety is everybody’s business, building and embedding a safety ...

Shouldering the burden of adverse event As primary care givers and clinical leaders, surgeons wil...