Oxford Professional Practice: Handbook of Patient Safety

Peter Lachman M.D. MPH. M.B.B.Ch., FRCPCH, FCP (SA), FRCPI is Lead Faculty Quality Improvement at the Royal College of Physicians of Ireland (RCPI) in Dublin, where he directs the Leadership and Quality programme to develop clinical leaders in quality improvement. He is co-founder and Chairperson of PIPSQC, the Paediatric International Patient Safety and Quality Community. He was Chief Executive Officer of the International Society for Quality in Healthcare (ISQua) from 1st May 2016 to 30th April 2021. Dr Lachman was a Health Foundation Quality Improvement Fellow at IHI in 2005-2006 and developed the safety programme at Great Ormond Street Hospital where he was the Deputy Medical Director with the lead for Patient Safety. He was also a Consultant Paediatrician at the Royal Free Hospital in London specialising in the challenge of long term conditions for children. Dr. Anita Jayadev qualified from St. Bartholomews School of Medicine and Dentistry in London in 2005 and works as a respiratory consultant with an interest in sleep medicine. She has led several projects and developed new services to improve patient safety and care. Her achievements were recognised by the HSJ and she was awarded 'Rising Star in the NHS award' during her training and won the BMJ patient safety team of the year award during her Darzi Fellowship at Great Ormond Street Hospital. She continues to work as the clinical Quality Improvement lead at Wexham Park Hospital and is the Trust Sepsis lead. Dr. John Brennan is a General Practitioner and was awarded a Diploma in Quality Improvement in Healthcare and Patient Safety with the Royal College of Physicians of Ireland (RCPI) in 2017. He served as Quality Improvement Scholar in Residence with the RCPI and the International Society for Quality in Healthcare (ISQua) in 2016/17. As well as being an ISQua Fellow and Board Member, John currently works with the RCPI in designing and delivering Quality Improvement and Patient Safety education across a number of platforms, including in collaboration with the Health Service Executive. He is lead QI Faculty for the National COPD Improvement Collaborative in Ireland. Dr. John Fitzsimons is a Paediatrician at Children's University Hospital, Temple St and Clinical Director with the Health Service Executive's (HSE) National Quality Improvement Team. He graduated from University College Dublin in 1996. He trained as a Patient Safety Officer with the Institute of Healthcare Improvement (IHI) and was a fellow of the Improvement Faculty at the NHS Institute for Improvement & Innovation before returning to work in Ireland in 2010. He is course co-director of the Quality Improvement and Leadership Programme which has been run in partnership between the HSE and the Royal College of Physicians in Ireland (RCPI) since 2011. Dr Jane Runnacles MBBS MA MRCPCH PGcert (healthcare leadership). Jane is a Consultant in Ambulatory Paediatrics at St George's hospital NHS Foundation Trust, London and clinical governance lead for her department. She has an interest in acute paediatrics, simulation and quality improvement (QI). During her postgraduate training in London, she was awarded distinction in her MA in clinical education and spent a year as a Darzi clinical leadership fellow at Great Ormond Street Hospital. Jane is a Training Programme Director for the London School of Paediatrics and leads their leadership and QI education programmes.

Part 1 Introduction to science and theory of patient safety
1: Peter Lachman & John Fitzsimons: The Rationale and science of Patient Safety
2: Ahmeda Ali & John Fitzsimons: The Culture and system of Patient Safety
3: Blair L. Sadler & Peter Lachman: Transparent Leadership for safety
4: John Brennan, Eugene Nelson, Sibylle Erdmann & Margaret Murphy: Codesigning for Safety and Patients Leading for Safety
5: James F O'Mahony: The Economics of Patient Safety
6: Patricia O'Connor: Developing a Safe Clinical Team
7: David Crosby & Peter Lachman: Communicating to be Safe
8: Eoin Fitzgerald & Peter Lachman: Situation Awareness and patient safety
9: Thomas Jun & Sue Hignett: Practical Application of Human Factors and ergonomics to Improve Safety
10: Uma Kotagal & Peter Lachman: Reliability Theory and its application in daily work and standardisation
11: Kate Churruca, Robyn Clay-Williams, Janet C Long, Louise A Ellis & Jeffrey Braithwaite: Resilience Theory, Complexity Science and Safety 2
Part 2 Practical application and methodologies of patient safety
12: Jason Leitch & Thomas Lamont: Measuring Patient Safety at a System, Organisation and National Level
13: Jane Runnacles & John Fitzsimons: How to Measure Patient Safety on the Front Line
14: Peter Lachman, Susanne O'Reilly, Michael Marx and John Brennan: Improving to be Safe
15: Adrian Plunkett: Learning from Success to be safer
16: Kevin Stewart & Rachel Pool: Investigating and learning from Adverse Events
17: Mark O'Brien & Pallavi Bradshaw: Open Disclosure
18: Kris Vanhaecht: Caring for the Caregivers - The Second Victim
Part 3 Translating theory to clinical practice
19: Christopher Cornue: Safety and information technology
20: Frank Frederico: Enabling Medication Safety
21: James Hoffman & Kristen Hughes: Paediatric medication safety
22: Rob Cunney: Preventing and Decreasing Infections
23: Rob Cunney: Sepsis and Antimicrobial stewardship
24: Anita Jayadev, Karen Britton & Shefal Patel:: Detecting and Limiting Deterioration
25: Tricia Woodhead and Gail Nielsen: Preventing and Limiting Diagnostic Error
26: John Brennan: Safety in Primary Care and General Practice
27: Damian Roland & Jay Banerjee: Safety in the Emergency Department
28: Anita Jayadev & Sean Harding: Safety in Outpatients and Ambulatory Care
29: Rob Bethune: Safety in the operating theatre
30: Jane Runnacles: Safety in Paediatrics and Child Health
31: David Crosby: Safety in Maternity and Women's Health
32: Daniel Hayes: Safety in Mental Health
33: Kevin Rooney & Suying Ong: Safety in Intensive Care
34: Kirstyn James: Safety in Patients with Frailty and Complex Long-Term Conditions
35: Kieran Murray & Michael Marx: Safety in a multi-disciplinary team
36: Kevin O'Hare: Safety in the laboratory
37: Riccardo Trataglia, Micaela La Regina and Peter Lachman: Safety in a pandemic