Oxford Professional Practice: Handbook of Patient Safety

Peter Lachman, Lead Faculty Quality Improvement Programme, Royal College of Physicians of Ireland,Jane Runnacles, Consultant Paediatrician, St Georges University Hospital NHS Trust,Anita Jayadev, Consultant Respiratory Physician, Wexham Park Foundation NHS Trust,John Brennan, General Practitioner,
Quality Improvement and Patient Safety Faculty, Royal College of Physicians of Ireland,John Fitzsimons, Consultant Paediatrician, Temple Street Childrens Hospital, Dublin

Peter Lachman M.D. MPH. M.B.B.Ch., FRCPCH, FCP (SA), FRCPI is Lead Faculty Quality Improvement at the Royal College of Physicians of Ireland (RCPI) in Dublin, where he directs the Leadership and Quality programme to develop clinical leaders in quality improvement. He is co-founder and Chairperson
of PIPSQC, the Paediatric International Patient Safety and Quality Community.

He was Chief Executive Officer of the International Society for Quality in Healthcare (ISQua) from 1st May 2016 to 30th April 2021. Dr Lachman was a Health Foundation Quality Improvement Fellow at IHI in 2005-2006 and developed the safety programme at Great Ormond Street Hospital where he was the
Deputy Medical Director with the lead for Patient Safety. He was also a Consultant Paediatrician at the Royal Free Hospital in London specialising in the challenge of long term conditions for children.

Dr. Anita Jayadev qualified from St. Bartholomews School of Medicine and Dentistry in London in 2005 and works as a respiratory consultant with an interest in sleep medicine. She has led several projects and developed new services to improve patient safety and care. Her achievements were recognised
by the HSJ and she was awarded 'Rising Star in the NHS award' during her training and won the BMJ patient safety team of the year award during her Darzi Fellowship at Great Ormond Street Hospital. She continues to work as the clinical Quality Improvement lead at Wexham Park Hospital and is the Trust
Sepsis lead.


Dr. John Brennan is a General Practitioner and was awarded a Diploma in Quality Improvement in Healthcare and Patient Safety with the Royal College of Physicians of Ireland (RCPI) in 2017. He served as Quality Improvement Scholar in Residence with the RCPI and the International Society for Quality
in Healthcare (ISQua) in 2016/17. As well as being an ISQua Fellow and Board Member, John currently works with the RCPI in designing and delivering Quality Improvement and Patient Safety education across a number of platforms, including in collaboration with the Health Service Executive. He is lead
QI Faculty for the National COPD Improvement Collaborative in Ireland.


Dr. John Fitzsimons is a Paediatrician at Children's University Hospital, Temple St and Clinical Director with the Health Service Executive's (HSE) National Quality Improvement Team. He graduated from University College Dublin in 1996. He trained as a Patient Safety Officer with the Institute of
Healthcare Improvement (IHI) and was a fellow of the Improvement Faculty at the NHS Institute for Improvement & Innovation before returning to work in Ireland in 2010. He is course co-director of the Quality Improvement and Leadership Programme which has been run in partnership between the HSE and
the Royal College of Physicians in Ireland (RCPI) since 2011.

Dr Jane Runnacles MBBS MA MRCPCH PGcert (healthcare leadership).

Jane is a Consultant in Ambulatory Paediatrics at St George's hospital NHS Foundation Trust, London and clinical governance lead for her department. She has an interest in acute paediatrics, simulation and quality improvement (QI). During her postgraduate training in London, she was awarded
distinction in her MA in clinical education and spent a year as a Darzi clinical leadership fellow at Great Ormond Street Hospital. Jane is a Training Programme Director for the London School of Paediatrics and leads their leadership and QI education programmes.

Part 1 Introduction to science and theory of patient safety
1. The Rationale and science of Patient Safety, Peter Lachman & John Fitzsimons
2. The Culture and system of Patient Safety, Ahmeda Ali & John Fitzsimons
3. Transparent Leadership for safety, Blair L. Sadler & Peter Lachman
4. Codesigning for Safety and Patients Leading for Safety, John Brennan, Eugene Nelson, Sibylle Erdmann & Margaret Murphy
5. The Economics of Patient Safety, James F O'Mahony
6. Developing a Safe Clinical Team, Patricia O'Connor
7. Communicating to be Safe, David Crosby & Peter Lachman
8. Situation Awareness and patient safety, Eoin Fitzgerald & Peter Lachman
9. Practical Application of Human Factors and ergonomics to Improve Safety, Sue Hignett & Thomas Jun
10. Reliability Theory and its application in daily work and standardisation, Uma Kotagal & Peter Lachman
11. Resilience Theory, Complexity Science and Safety 2, Kate Churruca, Robyn Clay-Williams, Janet C Long, Louise A Ellis & Jeffrey Braithwaite
Part 2 Practical application and methodologies of patient safety
12. Measuring Patient Safety at a System, Organisation and National Level, Jason Leitch & Thomas Lamont
13. How to Measure Patient Safety on the Front Line, Jane Runnacles & John Fitzsimons
14. Improving to be Safe, Peter Lachman & John Brennan
15. Learning from Success to be safer, Adrian Plunkett
16. Investigating and learning from Adverse Events, Kevin Stewart & Rachel Pool
17. Open Disclosure, Mark O'Brien & Pailavi Bradshaw
18. Caring for the Caregivers - The Second Victim, Kris Vanhaecht
Part 3 Translating theory to clinical practice
19. Safety and information technology, Chris Cornue
20. Enabling Medication Safety, Frank Frederico
21. Paediatric medication safety, James Hoffman & Kristen Hughes
22. Preventing and Decreasing Infections, Rob Cunney
23. Sepsis and Antimicrobial stewardship, Rob Cunney
24. Detecting and Limiting Deterioration, Anita Jayadev, Karen Britton & Shefal Patel:
25. Preventing and Limiting Diagnostic Error, Trish Woodhead & Gail Nielsen
26. Safety in Primary Care and General Practice, John Brennan
27. Safety in the Emergency Department, Damian Roland & Jay Banerjee
28. Safety in Outpatients and Ambulatory Care, Anita Jayadev & Sean Harding
29. Invasive Procedural Safety inside and outside the Operating Theatre, Rob Bethune
30. Safety in Paediatrics and Child Health, Jane Runnacles
31. Safety in Maternity and Women's Health, David Crosby
32. Safety in Mental Health, Daniel Hayes
33. Safety in Intensive Care, Kevin Rooney & Suying Ong
34. Safety in Patients with Frailty and Complex Long-Term Conditions, Kirstyn James
35. Safety in a multi-disciplinary team, Kieran Murray & Michael Marx
36. Safety in the laboratory, Kevin O'Hare
37. Safety in a pandemic, Peter Lachman