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Practical Patient Safety


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Table of Contents

1: The scale of the problem 2: Clinical errors: What are they? 3: Safety culture in high reliability organisations 4: Case studies 5: Error management 6: Communication failure 7: Situation awareness 8: Professional culture 9: When carers deliberately cause harm 10: Patient safety toolbox 11: Glossary 12: Conclusion Appendices

About the Author

John Reynard is a consultant urological surgeon in the Nuffield Department of Surgery in Oxford and an honorary consultant urologist to the National Spinal Injury Centre at Stoke Mandeville Hospital. He read physiological sciences at Lady Margaret Hall in Oxford and competed his clinical studies at the London Hospital Medical College, qualifying in 1987. After basic surgical training in London and research at the Bristol Urological Institute he specialized in urology at St Bartholomew's and The Royal London Hospitals, completing his training in Christchurch in New Zealand before returning to Oxford. Along with Peter Stevenson he has delivered Patients Safety Training to medical students and junior doctors in Oxford since 2003, and is member of the Clinical Human Factors Group - an organisation consisting of airline patients, human factors experts, and doctors dedicated to the promotion of human factors training in healthcare. John Reynolds studied medicine at Downing College Cambridge and St Catherine's College Oxford, and qualified in 1981. He was Clinical Lecturer in Clinical Pharmacology at Oxford University from 1990 to 1997 and obtained his DPhil in neuropharmacology in 1996. In 1997 he was appointed as a consultant physician and clinical pharmacologist at the John Radcliffe Hospital in Oxford. As a practicing general physician he has a full time clinical commitment to acute general medicine at the John Radcliffe Hospital. He has also been very actively involved in local prescribing both in a management role and in post-graduate education. He is a member of the Oxfordshire Area Prescribing Committee, the local Cancer Therapeutics Committee, Antimicrobial Prescribing Committee, and the Oxfordshire Priorities Forum, and he chairs the Oxford Radcliffe Hospitals Medicines Advisory Committee. Peter Stevenson is a commercial pilot flying wide-body airliners on long-haul routes for a major British airline. In the early 1990s he developed and presented Crew Resource Management (CRM) training courses for pilots in his airline. These courses were based around learning the lessons from dozens of air disasters in the 1970s and 1980s. In 2000 he helped the Post Graduate Medical Education Centres of two NHS hospitals to create a healthcare version of the CRM course. He has prepared and delivered a programme of Patient Safety Training for medical students at the Nuffield Department of Surgery at the University of Oxford from 2003 onwards.


The authors' last paragraph says 'Be brave. The fact that you have bought this book means you are in the vanguard of change'. Those bringing up the rear, who have not bought it, should borrow a copy from their more enlightened colleagues. * British Journal of Hospital Medicine *
This excellent volume delivers crucial information and advice, elegantly presented in a practical and trim format. Its 345 grams sit easily in the pocket of a white coat and to adapt a metaphor to recognise the importance of hand function, it punches well above its weight. * Journal of Surg Eng *

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