Clinical risk management : enhancing patient safety

584 Pages·2001·3.567 MB·English

by  Charles Vincent, Dr

BMJ 1107 Clinical Risk Man cov 23/10/00 12:46 pm Page 1
EC S e c o n d e d i t i o n
n
hl
Since publication of this award winning book, the field of clinical risk management ai
n
has developed rapidly. Patient safety is now a major concern in every advanced n
healthcare system. ci
i
nc
Clinical Risk Managementis already established as the standard text. This g
a

second edition has been completely revised, by an internationally renowned group p
l
of authors, to reflect the recent developments. All chapters have been updated, a

and many new ones added, with an entirely new section on the conditions of safe tiR
e
practice. The text is research based but the emphasis is always towards
ni
addressing practical clinical problems, reducing adverse events, and enhancing t s Clinical
patient safety. sk
a
Sections include: f
e
M
t
y
Principles of risk management– understanding adverse events;
development of clinical risk management and clinical governance. a
n
Reducing risk in clinical practice– in obstetrics, paediatrics, anaesthesia, RISK
emergency medicine and other specialties. a
g
The conditions of safe practice– communicating with patients and their
families; the role of human factors such as working time, stress, and fatigue. e Management
m
Implementation of risk management– clinical incident reporting; caring
for patients harmed by treatment; supporting staff involved in incidents;
e
resolving disputes.
n
No one concerned with risk and patient safety should be without this book.
t Enhancing patient safety
No longer can health care professionals ignore the issues it discusses, or the help
it provides. Patients, health care researchers, policy makers and lawyers will also
find the information invaluable.
eS
de
ic
to
i
on
nd

Medicine/General Issues/
ISBN 0-7279-1392-1
V
i
n Charles Vincent
Edited by
c
e
9 780727 913920 n
t
www.bmjbooks.com
CLINICAL RISK
MANAGEMENT
Enhancing patient safety
Second edition
Edited by
CHARLES VINCENT
Professor of Psychology, University College London,
London, UK
BMJ
Books
© BMJ Books 2001
BMJ Books is an imprint of the BMJ Publishing Group
All rights reserved.No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording and/or otherwise, without the prior written permission of the publishers.
First published in 1995
by the BMJ Publishing Group, BMAHouse, Tavistock Square,
London WC1H 9JR
www.bmjbooks.com
First edition 1995
Second edition 2001
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN 0 7279 1392 1
Cover by Landmark Design, Croydon, Surrey
Typeset by J&L Composition Ltd, Filey, North Yorkshire
Printed and bound by MPG Books Ltd, Bodmin, Cornwall
Contents
CONTRIBUTORS vi
ACKNOWLEDGEMENTS x
INTRODUCTION 1
CHARLES VINCENT
PART I: PRINCIPLES OF RISK MANAGEMENT
1 Understanding adverse events: the human factor 9
JAMES T REASON
2 Errors and adverse events in medicine: an overview 31
ERIC J THOMAS, TROYEN A BRENNAN
3 The development of clinical risk management 45
KIERAN WALSHE
4 Clinical governance: the context of risk management 61
JONATHAN SECKER-WALKER, LIAM DONALDSON
PART II: REDUCING RISK IN CLINICAL PRACTICE
5 Reducing risk in obstetrics 77
JAMES DRIFE
6 Reducing risk in paediatrics and neonatal intensive care 95
PETER DEAR
7 Clinical risk management in anaesthesia 111
JAN DAVIES, ALAN AITKENHEAD
8 Risk management in surgery 137
JOHN WILLIAMS
9 Risk management in accident and emergency medicine 151
PETER DRISCOLL, MARTIN THOMAS, ROBIN TOUQUET,
JANE FOTHERGILL
iii
CONTENTS
10 Reducing risks in the practice of hospital general 175
medicine
GRAHAM NEALE
11 Risk management in clinical oncology 197
GARETH REES
12 Risk management in psychiatry 219
MAURICE LIPSEDGE
13 Risk management in general practice 241
STEPHEN ROGERS
PART III: THE CONDITIONS OF SAFE PRACTICE
14 Communicating risk to patients and families 263
JAMES W PICHERT, GERALD B HICKSON
15 Guidelines and pathways 283
ROBBIE FOY, JEREMY GRIMSHAW, MARTIN ECCLES
16 The role of human factors engineering in medical 301
device and medical system errors
JOHN GOSBEE, LAURA LIN
17 Working time, stress and fatigue 319
LAWRENCE SMITH
18 Training and supervision 341
FIONA MOSS, ELISABETH PAICE
19 Teams, culture and managing risk 355
JENNY FIRTH-COZENS
20 Creating and maintaining safe systems of medical 369
care: the role of risk management
PETER PRONOVOST, LAURA MORLOCK, CHRISTOPHER CASSIRER
PART IV: IMPLEMENTATION OF RISK MANAGEMENT
21 Implementation of risk management 389
RICHARD W BEARD, ANNE O’CONNOR, PATRICIA SCOTT
22 Clinical incident reporting 419
JONATHAN SECKER-WALKER, SALLY TAYLOR-ADAMS
23 The investigation and analysis of clinical incidents 439
CHARLES VINCENT, SALLY TAYLOR-ADAMS
24 Caring for patients harmed by treatment 461
CHARLES VINCENT
25 Supporting staff involved in serious incidents 481
and during litigation
DAVID HEWETT
iv
CONTENTS
26 Dealing with clinical complaints 497
JUDITH ALLSOP, LINDA MULCAHY
27 Resolving disputes about clinical accidents 519
ARNOLD SIMANOWITZ, HENRY BROWN
28 Claims management 539
E JANE CHAPMAN
Index 555
v
Contributors
Alan Aitkenhead Professor of Anaesthesia, Department of Anaesthesia
and Intensive Care,SchoolofMedicineandSurgicalSciences,University
of Nottingham, Nottingham, UK
Judith Allsop Professor in Health Policy, De Montfort University,
Leicester, UK
Richard W BeardProfessor of Obstetrics and Gynaecology, North West
London Hospital’s NHS Trust, Harrow, UK
Troyen A Brennan Professor of Medicine, Harvard Medical School and
Harvard School of Public Health, Boston, USA
Henry Brown Solicitor, Penningtons, London, UK
Christopher Cassirer Associate Professor, Department of Healthcare,
University of Minnesota, USA
E Jane Chapman General Manager, Risk & Legal Services, North West
London Hospital’s NHS Trust, Harrow, UK
Jan Davies Professor of Anaesthesia, Foothills Medical Centre, University
of Calgary, Canada
Peter Dear Consultant in Neonatal Medicine, St James’ University
Hospital, Leeds, UK
Liam Donaldson Chief Medical Officer, Richmond House, London,
UK
James Drife Professor of Obstetrics and Gynaecology, School of
Medicine, University of Leeds, Leeds, UK
Peter Driscoll Consultant in Accident & Emergency Medicine, Hope
Hospital, Manchester, UK
vi
CONTRIBUTORS
Martin Eccles Professor of Clinical Effectiveness, Centre for Health
Services Research, University of Newcastle Upon Tyne,
Newcastle upon Tyne, UK
JennyFirth-CozensProfessor of Psychology, CentreforClinical
Psychologyand Health Care Research,UniversityofNorthumbriaat
Newcastle,NewcastleuponTyne,UK
Jane Fothergill Consultant in Accident & Emergency Medicine,
St Mary’s Hospital, London, UK
Robbie Foy MRC Training Fellow in Health Services Research,
Department of Obstetrics and Gynaecology, University of Edinburgh,
Edinburgh, UK
John Gosbee Director of the National Patient Safety Register, VHA
National Center for Patient Safety, Michigan, USA
Jeremy Grimshaw Professor of Health Services Research, University of
Aberdeen, Aberdeen, UK
David Hewett Assistant Medical Director, Winchester & Eastleigh
Healthcare Trust, Winchester, UK
Gerald B Hickson Professor of Pediatrics, Vanderbilt University
Medical Center, Nashville, USA
Laura Lin Human Factors Engineer, Logicon, Inc, Dayton, USA
Maurice Lipsedge Consultant Psychiatrist, South London and
Maudsley NHS Trust, London, UK
Laura Morlock Professor of Health Policy and Management,
Johns Hopkins University, Baltimore, USA
FionaMossAssociateDean,NorthThamesDepartmentofPostgraduate
Medical and Dental Education, University of London, London, UK
Linda Mulcahy Reader in Law, Birkbeck College, University of
London, London, UK
Graham Neale Consultant Physician, Clinical Risk Unit, Department
of Psychology, University College, London, UK
Anne O’Connor Risk Management Adviser, St Paul International
Insurance Co Ltd, Redhill, UK
ElisabethPaiceDeanDirector,NorthThamesDepartmentof
PostgraduateMedicalandDentalEducation,UniversityofLondon,
London,UK
vii
CONTRIBUTORS
James W Pichert Associate Professor of Education in Medicine, School
of Medicine, Vanderbilt University, Nashville, USA
Peter Pronovost Assistant Professor of Anesthesiology and Critical
Care Medicine, The Johns Hopkins Hospital, Baltimore, USA
James T Reason Professor of Psychology, University of Manchester,
Manchester, UK
Gareth Rees Consultant in Clinical Oncology and Clinical Director,
Bristol Haematology and Oncology Centre, Bristol Royal Infirmary,
Bristol, UK
Stephen Rogers Senior Lecturer in Primary Care, Royal Free and
University College Medical School, London, UK
Patricia Scott Risk Manager, Birth Unit, Hospital of St John and
St Elizabeth, London, UK
Jonathan Secker-Walker Senior Lecturer, Department of Clinical
Governance, University of Wales College of Medicine, Cardiff, UK
Arnold Simanowitz Chief Executive, Action for Victims of Medical
Accidents, Croydon, UK
Lawrence Smith Shiftwork Research Group, School of Psychology,
University of Leeds, Leeds, UK
Sally Taylor-Adams Senior Risk Management Consultant, Greenstreet
Berman, Reading, UK
Eric J Thomas Assistant Professor of Medicine, Houston Medical
School, University of Texas, Houston, USA
Martin Thomas Clinical Research Fellow, Accident and Emergency
Department, Manchester Royal Infirmary, Manchester, UK
Robin Touquet Consultant in Accident and Emergency Medicine,
St Mary’s Hospital, London, UK
Charles Vincent Professor of Psychology, University College London,
London, UK
Kieran Walshe Senior Research Fellow, Health Services Management
Centre, University of Birmingham, Birmingham, UK
John Williams Consultant in Maxillofacial Surgery, St Richard’s
Hospital, Chichester,UK
viii
To
Marjorie Howard
ix