Although many factors influence the incidence of medical error and adverse patient outcome, this chapter focuses on human and system performance and its impact on patient safety in the delivery room. First, we review general concepts and models of patient safety. Second, approaches taken by high-risk industries other than healthcare to improve human and system performance will be explored. Next, how those approaches can be adapted and adopted to address similar safety problems in healthcare will be discussed. Finally, we underscore how human factors research in healthcare can be used to improve patient safety. Healthcare must incorporate objective performance data, briefing, debriefing, simulation, and human factors science to identify and remediate human and system weaknesses inherent in patient care. Only then will we be able to improve performance, reduce error, and minimize risk.

Chapter 2.3 reports on low-value care and how to reduce waste. Decommissioning or disinvesting from low value care means taking money away from health care services that give poor value for money. Key learning includes that

• Ending investment in health technologies or treatments that are ineffective releases resources for more effective high-value care, increases efficiency and quality and contributes to sustainability.

• Disinvesting from or decommissioning low-value care often faces institutional barriers.

• Health technology assessment (HTA) and the continuous monitoring of peer-reviewed evidence and administrative health care data are key in identifying low-value care and prioritizing what should be decommissioned.

• Combining financial and non-financial mechanisms can help influence both the supply of and demand for low-value care and stop its provision.

• Broad stakeholder consultation and engagement is a key part of ending the use of low-value care because patients, clinicians, health related organizations and health system norms and structures can all create barriers to change.

• Decision-makers need to address how resources released by disinvestment can best be re-invested to strengthen efficiency, quality and access.

Patient safety is a critical challenge in modern healthcare, with significant mortality rates due to lapses in safety protocols. This chapter explores the multifaceted nature of patient safety, emphasizing procedural skills competency, critical thinking, and effective team communication. Simulation is recognized as an optimal educational tool, offering a risk-free environment to practice common and rare clinical scenarios.

Various simulation modalities, including high-fidelity simulation (HFS), standardized patients, virtual reality, and screen-based simulations, have distinct roles in identifying and addressing patient safety gaps. In situ simulation, conducted in real clinical environments, and simulation center-based training each have advantages and challenges.

In situ simulation enhances realism but poses logistical challenges, while simulation centers offer controlled environments with advanced equipment. Clear learning objectives and performance metrics are essential for effective simulation-based training, as demonstrated by the successful training outcomes at Louisiana State University Health Sciences Center.

Research findings indicate that while simulation training effectively improves skills in the short term, repeated practice is necessary for long-term retention. The COVID-19 pandemic has significantly impacted the planning and delivery of simulation training, leading to innovations in remote learning through virtual reality and online modules. Future directions for simulation in healthcare include increased accessibility, integration with telemedicine, and artificial intelligence for personalized learning.

Simulation is a flexible and proven methodology to enhance patient safety through ongoing clinician education and health systems improvement.

This chapter delves into the role and benefits of Anesthesia Information Management Systems (AIMS) for out-of-operating-room (OOR) settings. AIMS enables anesthesiologists to focus on patient care while ensuring efficient workflows, quality assurance, compliance, and data-driven clinical decisions. Key features such as real-time alerts, integration with electronic health records (EHRs), and data analytics enhance patient safety and operational efficiency. The chapter explores the advantages of AIMS in reducing procedure cancellations, streamlining preoperative processes, and supporting quality improvement initiatives through data aggregation and benchmarking. Practical guidance is provided on selecting, implementing, and securing AIMS, emphasizing the importance of compatibility with existing systems, usability, and information security. Barriers to adoption, such as costs and technical challenges, are addressed alongside strategies for overcoming them. The chapter underscores the transformative potential of AIMS in modernizing anesthesia practice in OOR settings, ultimately contributing to better patient outcomes and healthcare efficiency

Despite remarkable surgical advances, knowledge, and training, the reliability of patient care needs to be more robust, and affordable. Surgical teams struggle to design, implement, and maintain processes that optimize human performance, reduce risk, and ensure highly reliable, safe outcomes. Solutions for caregivers, especially those on the frontlines, remain elusive. This chapter helps to demystify the complex reality of our surgical processes, exploring how disruptions impact outcomes. It provides the tools to empower people and teams to provide the most effective, safe, and reliable care by improving process flow.

In this chapter, clinical practice is addressed from three perspectives. First, what does good clinical practice in suicide prevention look like? Secondly, there are key matters pertaining to how we both maintain patient safety and avoid iatrogenic harm. These include: an excessive focus on risk; the way in which people can and do fall through gaps between services; the continued use of, contrary to evidence, guidance and humane clinical practice, of behavioural management approaches to self-harm and suicidality, and the risks to patients and service users of ‘group think’ and malignant alienation in clinical cultures. Finally, we will consider what needs to be done to maintain positive standards and values in clinical settings.

Intrapartum events have resulted in maternal and perinatal morbidity and mortality and rising medico-legal claims related to maternity. Despite rapid technological advances recently, the rates of clinical incidents such as PPH, OASI and adverse fetal outcomes have not reduced significantly. Furthermore, new intrapartum incidents such as impacted fetal head, caring for mothers with high BMI and managing extreme preterm labour are on the rise. Empowering patients and their unrealistic expectations and workforce issues further complicate this issue. Many reports have indicated more than 50% of these are preventable. Various strategies at the institutional, process and clinical levels used to minimise labour risk are discussed. Some include staff numbers, fatigue, skill mix, training, guidelines, algorithms and partnership with patents. Interventions to reduce a few clinical conditions are discussed. We made suggestions based on pilot studies on how we could improve intrapartum care using modern technology, including AI.

Despite technological and scientific improvements in maternity care, mothers and babies continue to come to harm. As with other safety-critical industries, mistakes occur as a result of ‘human’ and ‘system’ errors. A sound understanding of non-technical skills can help explain past errors and prevent future errors; these skills include cognitive (situation awareness and decision-making) and social (teamwork, leadership and communication) aspects. Caring for mothers and babies is compromised by individuals and teams feeling stressed and exhausted, and it is increasingly recognised that a focus on individual/team human factors may be both ineffective and punitive. Improvements in safety culture therefore require both system redesign and compassionate leadership.

Deprescribing is the practice of stopping or reducing the dose of medicines that may be causing more harm than benefit to patients. Deprescribing can help prevent overprescribing, which can lead to adverse effects, unnecessary costs, or lack of efficacy. By deprescribing, patients can avoid medication-related problems, simplify their medication regimen, and enhance their wellbeing with non-pharmacological interventions. However, deprescribing is not without risks. Patients may experience withdrawal symptoms or recurrence of their original condition, which require careful monitoring and support. Deprescribing also faces several barriers, such as limited time and resources for clinicians, lack of clear guidelines, and patient reluctance or attachment to their medicines. To overcome these challenges, deprescribing should be based on a strong clinician–patient relationship, a gradual and individualised process, a multidisciplinary team approach, and a shared decision making model. Deprescribing can also be guided by various frameworks that help clinicians review, assess, prioritise, and follow-up on patients’ medications. There are tools that help identify potentially inappropriate or unnecessary medications and provide recommendations for deprescribing.

Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care. Anaesthetists have been leaders in patient safety for decades. In the United Kingdom, wholesale reform of children’s surgical delivery was undertaken after review of paediatric surgical outcomes in the 1990s, and in cardiac surgery, after an anaesthetist noted poor patient outcomes in children undergoing the arterial switch operation (see Kennedy 1996 in ‘Further Reading’).