01667nam2-2200529---450-99000055720020331620090723125405.088-14-06674-40055720USA010055720(ALEPH)000055720USA01005572020010710d1997----km-y0itay0103----baitaIT||||||||001yy<<3 :>> <<L'>> assemblea, l'amministratoreMaurizio De Tilla5. ed.MilanoGiuffrècopyr. 1997683 p.24 cm20010010002409172001<<Il>> condominioCondominioAssebleeCondominioAmministratore346.450433DE TILLA,Maurizio7752ITsalbcISBD990000557200203316TRA B 1/iv-31201 DIRCEXXV.1.B 475/4.3 (IG II 501/7 3)15355 GXXV.1.B 475/4.3 (IG II)00241419BKDIRCEGIUPATTY9020010710USA01173820020403USA011705PATRY9020040406USA011639DIRCE9020050322USA011001DIRCE9020050322USA011031DIRCE9020050322USA011047DIRCE9020050524USA011323DIRCE9020050524USA011355DIRCE9020050524USA011357DIRCE9020050524USA011630DIRCE9020050525USA010929RSIAV39020090723USA011254Assemblea, l'amministratore884508UNISA03700oam 2200505I 450 991015488330332120240501170140.01-315-38090-01-4987-8117-910.1201/9781315380902 (CKB)4340000000018641(MiAaPQ)EBC4751229(OCoLC)964697910(BIP)61806075(BIP)55700818(EXLCZ)99434000000001864120180706h20172017 uy 0engurcnu||||||||rdacontentrdamediardacarrierPatient safety investigating and reporting serious clinical incidents /Russell Kelsey, MB.BS MRCGP General Practitioner. Worcestershire, UK1st ed.Boca Raton :CRC Press,[2017]©20171 online resource (225 pages) color illustrationsIncludes index.1-4987-8116-0 Introduction : why do we still miss appendicitis? -- RCA : background and context -- How do we recognise serious clinical incidents? -- Recognising serious incidents using the SIRT : case studies -- A culture of complaint : openness, candour, and blame -- Root cause analysis : what happened? : the evidence -- Root cause analysis : what happened? : care and service delivery problems -- Root cause analysis : understanding why -- Understanding why : system factors -- Human factors part 1 : the key to enhanced learning -- Human factors part 2 : situational awareness and high pressure environments -- Root cause -- Learning and recommendations -- Solutions design and changing cultures -- Writing reports.At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.Medical errorsPreventionRoot cause analysisSafety regulationsMedical errorsPrevention.Root cause analysis.Safety regulations.610.28/9Kelsey Russell1241394FlBoTFGFlBoTFGBOOK9910154883303321Patient safety2879774UNINA