| Preface |
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vii | |
| Acknowledgements |
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xiii | |
| 1 Clinical error: the scale of the problem |
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1 | |
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The Harvard Medical Practice Study 1984 |
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2 | |
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The Quality in Australian Healthcare Study 1992 |
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3 | |
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The University College London Study 2001 |
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4 | |
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Danish, New Zealand, Canadian, and French studies |
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4 | |
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The frequency and costs of adverse drug events |
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4 | |
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Accuracy of retrospective studies |
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6 | |
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Error rates revealed in retrospective studies are of the same order of magnitude as those found in observational studies |
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7 | |
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Error rates according to type of clinical activity |
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7 | |
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Deaths from adverse events |
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9 | |
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Extra bed days as a consequence of error |
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10 | |
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Criminal prosecutions for medical errors |
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12 | |
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Reliability: other industries |
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12 | |
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12 | |
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13 | |
| 2 Clinical errors: What are they? |
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15 | |
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Sources of error in primary care and office practice |
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15 | |
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Sources of error along the patient pathway in hospital care and potential methods of error prevention |
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16 | |
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Errors in dealing with referral letters |
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16 | |
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17 | |
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26 | |
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Errors with medical records in general |
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26 | |
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Other slips in letters that you have dictated |
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27 | |
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Errors as a consequence of patients failing to attend appointments for investigations or for outpatient consultations |
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28 | |
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Washing your hands between patients and attention to infection control |
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28 | |
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32 | |
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Diagnostic errors in general |
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32 | |
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Errors in drug prescribing and administration |
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36 | |
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Reducing errors in blood transfusion |
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45 | |
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Intravenous drug administration |
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46 | |
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Errors in the operating theatre |
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47 | |
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48 | |
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Harm related to patient positioning |
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49 | |
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Leg supports that give way |
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52 | |
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Generic safety checks prior to any surgical procedure |
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52 | |
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Failure to give DVT prophylaxis |
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53 | |
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Failure to give antibiotic prophylaxis |
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53 | |
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Errors in the postoperative period |
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54 | |
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55 | |
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55 | |
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62 | |
| 3 Safety culture in high reliability organizations |
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65 | |
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High reliability organizations: background |
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65 | |
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High reliability organizations: common features |
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68 | |
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The consequences of failure |
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69 | |
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'Convergent evolution' and its implication for healthcare |
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71 | |
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Learning from accidents: overview of basic high reliability organizational culture |
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72 | |
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Elements of the safety culture |
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72 | |
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Counter-intuitive aspects of high reliability organization safety culture |
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78 | |
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83 | |
| 4 Case studies |
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Case study 1: wrong patient |
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87 | |
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Case study 2: wrong blood |
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88 | |
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Case study 3: wrong side nephrectomy |
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89 | |
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Case study 4: another wrong side nephrectomy |
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90 | |
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Case study 5: yet another wrong side nephrectomy case |
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93 | |
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Case study 6: medication error—wrong route (intrathecal vincristine) |
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Case study 7: another medication error—wrong route (intrathecal vincristine) |
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Case study 8: medication error—wrong route (intrathecal vincristine) |
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Case study 9: medication error—miscalculation of dose |
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100 | |
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Case study 10: medication error—frequency of administration mis-prescribed as 'daily' instead of 'weekly' |
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101 | |
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Case study 11: medication error—wrong drug |
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102 | |
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Case study 12: miscommunication of path lab result |
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103 | |
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Case study 13: biopsy results for two patients mixed up |
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105 | |
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Case study 14: penicillin allergy death |
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107 | |
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Case study 15: missing X-ray report |
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107 | |
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Case study 16: medication not given |
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108 | |
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Case study 17: oesophageal intubation |
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109 | |
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Case study 18: tiredness error |
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109 | |
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Case study 19: inadequate training |
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Case study 20: patient fatality—anaesthetist fell asleep |
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112 | |
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113 | |
| 5 Error management |
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115 | |
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How accidents happen: the person approach versus the systems approach |
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115 | |
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117 | |
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119 | |
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121 | |
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123 | |
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124 | |
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How experts and novices solve problems |
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126 | |
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Three error management opportunities |
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130 | |
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Detecting and reversing incipient adverse events in real time: 'Red flags' |
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134 | |
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Red flags: the symptoms and signs of evolving error chains |
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135 | |
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141 | |
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Error management using accident and incident data |
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144 | |
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148 | |
| 6 Communication failure |
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149 | |
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The prevalence of communication failures in adverse events in healthcare |
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150 | |
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Communication failure categories |
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153 | |
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Whose fault: message sender or receiver? |
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165 | |
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Safety-critical communications (SCC) protocols |
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166 | |
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How to prevent communication errors in specific healthcare situations |
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180 | |
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Composing an 'abnormal' (non-routine) safety-critical message |
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191 | |
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Written communication/documentation communication failures |
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197 | |
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198 | |
| 7 Situation awareness |
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201 | |
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Situation awareness: definitions |
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202 | |
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Three levels of situation awareness |
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202 | |
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Catastrophic loss of situation awareness and the associated syndrome: 'mind lock' |
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203 | |
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Understanding loss of situation awareness |
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207 | |
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Cognitive failures: the role of mental models/the psychology of mistakes |
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207 | |
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Mental models: the problems |
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208 | |
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Ensuring high situation awareness |
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213 | |
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Two special cases involving loss of situation awareness |
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220 | |
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244 | |
| 8 Professional culture |
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247 | |
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Similarities between two professions |
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247 | |
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Negative aspects of professional cultures |
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248 | |
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248 | |
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Changing the pilots' professional culture |
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250 | |
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Team resource management/non-technical skills |
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256 | |
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262 | |
| 9 When carers deliberately cause harm |
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263 | |
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265 | |
| 10 Patient safety toolbox |
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267 | |
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Practical ways to enhance the safety of your patients |
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267 | |
| 11 Conclusions |
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271 | |
| Glossary |
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275 | |
| Appendices |
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285 | |
| Appendix 1: Initiating a safety-critical (verbal) communication (STAR) |
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285 | |
| Appendix 2: I-SBAR—to describe a (deteriorating) patient's condition |
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286 | |
| Appendix 3: General patient safety tools |
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287 | |
| Appendix 4: Red flags (the symptoms and signs of an impending error) |
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289 | |
| Index |
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291 | |