uses 'real-life' examples to explain how adverse events can occur
develops the theme that behavior is the current weakest link in patient safety
shows the reader how to identify unsafe behaviors, lifting the taboo that prevents discussion around this theme and providing improvement possibilities
based on 15 years' practical experience in patient safety
accessible and interesting
Summary

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.

Table of Contents

Introduction

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