A better NHS also needs to be a safer NHS. In recent years, there has been an increasing realisation that we cannot simply take patient safety for granted, that hospitals and other healthcare settings can occasionally be dangerous places where harm can sometimes inadvertently come to patients, and that there have to be active efforts by all concerned to reduce the likelihood of this harm.
There has been a huge amount of research on patient safety in recent years, often taking into account major advances in our knowledge and understanding of human behaviour. In addition to general articles, some of the other papers below focus on my own area of interest – in general, the application of Psychology as a discipline to improving patient safety, and in particular diagnostic errors and the ways in which these errors can be better understood and prevented by the application of psychological principles.
As many of the articles below attest, there is an increasing recognition that human factors, and in particular cognitive and psychological variables, play a key part in ensuring patient safety. Every major hospital would benefit from having a post of ‘patient safety psychologist’.
General books and articles –
Ahmed M et al. (2012). Junior doctors’ reflections on patient safety. Postgraduate Medical Journal, 88: 125-29. PDF File
Chassin M, Loeb J. (2013). High reliability health care: Getting there from here. The Millbank Quarterly, 91: 459-90. PDF File
Croskerry P et al. (Eds). (2009). Patient Safety in Emergency Medicine. Philadelphia: Wolters Kluwer.
Dekker S. (2011). Patient Safety: A Human Factors Approach. Boca Raton, Florida: CRC Press.
Dyer, C. (2013). The long road to ensuring patient safety in NHS hospitals. BMJ, 346: f3029. PDF File
Flyn R. et al. (2013). Changing behaviour with a human factors approach. BMJ, 346: f1416. PDF File
Francis, R. (2104). The NHS must not slip back into bad old ways. The Times, February 6, 2014.PDF File
Jarman, B. (2013). Quality of care and patient safety in the UK: the way forward after Mid-Staffordshire. The Lancet, 382: 573-5. PDF File
Kapur, N. (2015). Professional bodies should provide accreditation of healthcare services to improve patient safety. BMJ, 351:h4420 PDF File
Kapur, N. (2015). Unconscious bias harms patients and staff. BMJ, 351:h6347 PDF File
Kapur, N. (2016). Keeping Kate Granger’s legacy alive. BMJ 2016;354:i4589 doi: 10.1136/bmj.i4589 PDF File
Macrae C, Vincent C. (2014). Learning from failure: the need for independent safety investigation in healthcare. Journal of the Royal Society of Medicine, 107: 439-43 . PDF file
Morello R. et al. (2012). Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Quality and Safety, 1-8. PDF File
National Advisory Group on Patient Safety [Berwick Report]. (2013). Improving the safety of patients in England. London: Department of Health. PDF File
Nuffield Foundation (2014). The Francis Report. One Year On. The Response of Acute Trusts in England. PDF File
Reid J, Catchpole K. (2011). Patient safety: a core value of nursing – so why is achieving it so difficult? Journal of Research in Nursing, 16: 209-223. PDF File
Robertson N. (2012). Improving patient safety: lessons from rock climbing. Clinical Teacher, 9: 41-44. PDF File
Rydon-Grange M. (2015). ‘What’s Psychology got to do with it?’ Applying psychological theory to understanding failures in modern healthcare settings. Journal of Medical Ethics, 41: 880-4.
Sanchez P. (Ed). (2012). Patient Safety. Surgical Clinics of North America, Volume 92, Issue 1.
Shekelle P et al. (2013). The top patient safety strategies that can be encouraged for adoption now. Annals of Internal Medicine, 158: 365-8. PDF File
Spiegelhalter D. (2013). Have there been 13,000 needless deaths at 14 NHS Trusts? BMJ, 347: f4893. PDF File
Toff N. (2010). Human actors in anaesthesia: lessons from aviation. British Journal of Anaesthesia, 105: 21-25. PDF File
Vincent C. (2010). Patient Safety. Second Edition. Chichester: Wiley-Blackwell.
Articles relating to diagnostic errors and patient safety –
Croskerry P. (2012). Perspectives on diagnostic failure and patient safety. Healthcare Quarterly, 15: 50-56. PDF File
Croskerry P, Nimmo G. (2012). Better clinical decision making and reducing diagnostic error. Journal of the Royal College of Physicians of Edinburgh, 41: 155-62. PDF File
Crowley R et al. (2012). Automated detection of heuristics and biases among pathologists in a computer-based system. Advances in Health Science and Education, published online. PDF File
Ely J et al. (2011). Checklists to reduce diagnostic errors. Academic Medicine, 86: 307-313. PDF File
Federspil G, Vettor R. (2008). Rational error in internal medicine. Internal and Emergency Medicine, 3: 25-31. PDF File
Gaber M et al. (2012). Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Quality & Safety, 21: 535-557. PDF File
Karl R, Karl M. (2012). Adverse events: root causes and latent factors. Surgical Clinics of North America, 92: 89-100. PDF File
Mamede S et al. (2012). Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. BMJ Quality and Safety, 21: 295-300. PDF File
Marewski J, Gigerenzer G. (2012). Heuristic decision making in medicine. Dialogues in Clinical Neuroscience, 14: 77-89. PDF File
Nendaz M, Perrier A. (2012). Diagnostic errors and flaws in clinical reasoning: mechanisms and prevention in practice. Swiss Medical Weekly, 142: 1-9. PDF File
Newman-Toker D, Pronovost P. (2009). Diagnostic errors – the next frontier for patient safety. Journal of the American Medical Association, JAMA. 301: 1060-62. PDF File
Newman-Toker D. (2013). From possible to probable to sure to wrong – premature closure and anchoring in a complicated case. Morbidity and Mortality Rounds, Agency for Healthcare Research and Quality, USA. PDF File
Poon E et al. (2012). Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. Journal of General and Internal Medicine, 26: 1416-23.PDF File
Schiff G et al. (2009). Diagnostic error in medicine. Archives of Internal Medicine, 169: 1881-7. PDF File
Schiff G, Leape L. (2012). How can we make diagnosis safer? Academic Medicine, 87: 135-8. PDF File
Singh H et al. (2013). Types and origins of diagnostic errors in primary care settings. JAMA Internal Medicine, 173: 418-25. PDF File
Vickery B et al. (2010). How neurologists think. A cognitive psychology perspective on missed diagnoses. Annals of Neurology, 67: 425-33. PDF File
Winters B et al. (2011). Reducing diagnostic errors: another role for checklists? Academic Medicine, 86: 279-81. PDF File
Zwaan L et al. (2012). Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Academic Medicine, 87: 149-56. PDF File
Other Resources –
Clinical Incident Analysis Framework (Narinder Kapur, Unpublished)
Patient Safety Website, events and resources –
Powerpoint presentation relating to Smart Papers –
Patient Safety Teaching Resource –
NHS Foresight Training Resource – videos and teaching materials that aim to help nurses and midwives develop the skills needed to identify situations when a patient safety incident is more likely to occur
Patient Safety General Resource –
Health Foundation Patient Safety Resource – a resource set up by the UK-based Health Foundation. This resource includes research papers, national standards, implementation guidelines and specific patient safety case studies.
Manchester Patient Safety Framework –
A framework to help understand, assess and evaluate patient safety in clinical settings (Download PDF File)