Author: Charles Vincent
This book addresses the wide-ranging subjects that constitute patient safety. This important topic is ‘…the foundation of good patient care…and the heart of healthcare quality’ (page ix). The author, a clinical safety research professor, sets out to explain ‘…the basic principles, characteristics and direction of the field’ (page ix). His target audience is a broad one; ‘…anyone interested or involved in healthcare…’ (page xi). He started by presenting a ‘brief’ history of medical harm, but detailed enough to constitute a book of its own. He pointed out the dearth of patient safety research prior to the mid 1990’s but acknowledged Ivan Illich who advocated for recognition of iatrogenesis– the harm medical activities cause (page 11). The history of the modern patient safety movement established the role played by physicians such as Lucian Leape, Donald Berwick, and Ernest Codman. The book reviewed some major healthcare tragedies that defined the field; it made special reference to the failures of the paediatric cardiac surgery unit of the Bristol Royal Infirmary (page 19).
The book then discusses the different types of healthcare-related adverse events and how frequently they occur. It makes reference to key research such as the Harvard Medical Practice Study (page 54). Giving illustrative examples, the book explores the psychological and environmental factors that contribute to errors and violations. It also discusses the skills and personal attributes that contribute to safety and recognised the impact of the Institute of Medicine report, To Err is Human, and the NHS paper, An Organization with a Memory, on doctors’ safe practice.
The author discussing patient safety
The author then explores error-reporting systems defining the ideal scheme as one that incorporates analysis, learning, feedback and action (page 91). He points out the barriers to error-reporting with relevant examples from aviation. He stresses the importance of measuring and tracking safety, and lists the patient safety indicators that aid this (page 107). He reviews different clinical incident investigation systems and states his preference of the ‘forward looking’ systems analysis over the ‘retrospective’ root cause analysis (RCA). He also describes human reliability analysis (HRA) and failure modes and effect analysis (FMEA).
In his review of the interventions which prevent errors, the author emphasised the importance of designing for safety, creating a safety culture, and measuring the safety climate. He addresses safety issues that arise in heath teams and discusses the significance of the shared mental model (page 342), crew resource management (page 345) and team training for safety (page 359). He noted the role patients could play in their own safety and listed steps they may take to prevent harm (page 292).
The fourth part of the book addresses the effect of adverse events and litigation on patients and medical staff, and it describes the support each require. It discussed the advantages of, and barriers to, open disclosure of harm to patients, noting that good open disclosure may prevent litigation (page 178). The book ends with a detailed discussion of the changes healthcare systems need to make to become high performing.
This is an all-embracing synopsis of patient safety. It covers the basic issues relevant to doctors’ safe practice whilst also addressing the deeper concerns of organisational safety. It is well-researched and a valuable resource; each chapter has a detailed reference list. The author made liberal use of boxes and this diminished their role of highlighting important concepts and issues. I thought they distracted from a smooth reading of the book. If one ignores these minor criticisms however, the content is unrivalled in its scope and attention to detail.
The main target audience for this book are those specifically interested in patient safety issues. The lay doctor may not find all the chapters relevant but will appreciate the subjects that comprise patient safety and the critical issues involved. It is an important contribution to the understanding of patient safety and I recommend it.
- Publisher, place, date: Wiley-Blackwell, Chichester, 2010
- Edition: 2nd
- Number of chapters: 20
- Pages: 416
- ISBN: 978-1-4051-9221-7
- Price: £38.94
- Star rating: 5 stars
- Other relevant book: Clinical Risk Management