Patient Safety

The second edition of this well-received book, the first to provide detailed guidance on how to conduct incident investigations in primary care, has been thoroughly revised and updated throughout to reflect the current nomenclature for different aspects of the investigatory process in the UK and the latest format for incident reporting.

Key features:


Explains how to recognise a serious clinical incident, how to conduct a root cause analysis (RCA) 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.


At a time of increasing regulatory scrutiny and medico-legal risk, in which failure to manage appropriately can have serious consequences both for service organisations and for individuals involved, this concise and convenient book continues to provide 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 incidents are investigated and managed.

About the Author. Introduction: Why do we still miss appendicitis? Clinical incident investigation: Background and context. How do we recognise patient safety incidents that need in-depth investigation? Recognising serious patient safety incidents using the SIRT: Case studies. A culture of complaint: Openness, candour and blame. RCA: Understanding what happened. RCA: Understanding how. RCA: Understanding why. Understanding why: System factors. Understanding why: Human error, Part 1. Understanding why: Human error, Part 2: Situational awareness and high-pressure environments. Root cause. Learning and recommendations. Solution design and changing cultures. Writing reports. Glossary. Index.