LEADER 02061oam 2200457I 450 001 9910154883303321 005 20230809233545.0 010 $a1-315-38090-0 010 $a1-4987-8117-9 024 7 $a10.1201/9781315380902 035 $a(CKB)4340000000018641 035 $a(MiAaPQ)EBC4751229 035 $a(OCoLC)964697910 035 $a(EXLCZ)994340000000018641 100 $a20180706h20172017 uy 0 101 0 $aeng 135 $aurcnu|||||||| 181 $2rdacontent 182 $2rdamedia 183 $2rdacarrier 200 10$aPatient safety $einvestigating and reporting serious clinical incidents /$fRussell Kelsey, MB.BS MRCGP General Practitioner. Worcestershire, UK 210 1$aBoca Raton :$cCRC Press,$d[2017] 210 4$dİ2017 215 $a1 online resource (225 pages) $ccolor illustrations 300 $aIncludes index. 311 $a1-4987-8116-0 327 $aIntroduction : 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. 606 $aMedical errors$xPrevention 606 $aRoot cause analysis 606 $aSafety regulations 615 0$aMedical errors$xPrevention. 615 0$aRoot cause analysis. 615 0$aSafety regulations. 676 $a610.28/9 700 $aKelsey$b Russell$01241394 801 0$bFlBoTFG 801 1$bFlBoTFG 906 $aBOOK 912 $a9910154883303321 996 $aPatient safety$92879774 997 $aUNINA