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Clinical risk management : enhancing patient safety by John Williams, Charles Vincent

By John Williams, Charles Vincent

The purpose of this publication is to minimize the hazards of scientific remedy and improve the protection of sufferers in all parts of healthcare. the 1st part discusses human errors, the occurrence of damage to sufferers, and the improvement or probability administration. Chapters within the moment part talk about the relief of chance in scientific perform in key clinical specialties. The 3rd part discusses beneficial properties of the healthcare structures which are necessary to secure perform, akin to verbal exchange of hazard to sufferers, the layout of apparatus, supervision and coaching, and powerful teamwork. The fourth part describes tips to placed danger administration into perform, together with the powerful and delicate dealing with of proceedings and claims, the care of injured sufferers and the workers concerned, and the reporting, research and research of great incidents.

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They included a diabolical conspiracy of all the usual suspects: human errors, faulty fuel gauges, systemic error traps and organisational failures. Only three paragraphs were devoted to the most remarkable aspect of the incident: what happened immediately after the engines stopped. Each pilot possessed life-saving knowledge and skills. The co-pilot had trained with the military and remembered that he had flown in and out of a now deserted airstrip at Gimli, only a few miles away. The captain was, in his spare time, an enthusiastic glider pilot.

Operating at the sharp end: the complexity of human error. In: Bogner MS, ed. Human errors in medicine. Hillsdale, NJ: Erlbaum, 1994:255–310. 2 Gaba DM. Human error in dynamic medical domains. In: Bogner MS, ed. Human errors in medicine. Hillsdale, NJ: Erlbaum, 1994:197–224. 3 Vincent C, Ennis M, Audley RJ. Medical accidents. Oxford: OUP, 1993. 4 Bogner MS. Human error in medicine. Hillsdale, NJ: Erlbaum, 1994. 5 Vincent C. Clinical risk management. London: BMJ Publications, 1995. 6 Hollnagel E.

Almost every study uses different methods, terms, and definitions. It is therefore almost impossible to make direct comparisons among studies, even among studies that purport to use the same methods. This is an important limitation given the tendency to interpret rates of errors and adverse events as a measure of quality and then to compare one healthcare site to another. Ideally, we could directly compare among hospitals or clinics in order to focus quality improvement and risk management efforts.

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