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  1. ALEX GATHERER, Clinical risk research associate

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    Clinical Risk Management. Edited by Charles Vincent. (Pp 588; £34.95 paperback.) BMJ Publishing Group, 1996. ISBN 0-7279-0947-9 .

    When the first conference on clinical risk management in this country was held in Oxford in 1989, there was very little experience here and the meeting had to draw heavily on experts from California, many of whom have contributed to this book. Since then, the position has changed quite dramatically. There can now be few doctors and nurses and even fewer health service managers who remain unaware of the size of the problem of medical litigation and of the implications for trusts. The publication of this book is therefore very timely.

    The approach taken by the editor is to gather together a wide range of experts from the several disciplines concerned so that all aspects of clinical risk management can be covered and a comprehensive picture presented. The book should be seen as a handbook and a source of reference, so that different readers can select those chapters which provide the guidance and background they need.

    The subjects covered range from general principles through risk management in high risk specialties to various important tasks in implementation and claims management. All the chapters will repay a quick read, while many can be strongly recommended for all clinical and non-clinical managers.

    Some idea of the scope of the book can be obtained by my referring to some of the contributions which I would list as essential reading. James Reason’s outline of the human factors involved in adverse events and the importance of organisational decisions helps to encourage a new and wider understanding of accidents and why they occur. I find his various distinctions, for example between slips, lapses and mistakes, of considerable assistance in clarifying in one’s mind just what we are up against in reducing risk. Robert Dingwall and Paul Fenn provide a chapter on financial implications and draw attention to the opportunity costs of risk management procedures and the estimated costs of alternatives such as no-fault schemes. Fiona Moss has the difficult but rewarding aim of placing risk management within the ‘clutch of programmes’ introduced to improve the quality of medical care. Laura Morlock writes about evaluation of clinical risk management programmes in the USA, giving her valuable views on what has been learnt there over 20 years.

    There are 10 chapters on reducing risks in clinical practice. The specialties covered include obstetrics, paediatrics and neonatal intensive care, anaesthesia, urology and general surgery, orthopaedics, and accident and emergency medicine. General practice is also included, as is psychiatry, nursing, and midwifery. These chapters should be read and considered within the appropriate divisions, bearing in mind that several dwell on what can go wrong rather than on experience gained in risk reduction. These should be used to encourage further work and pilot schemes necessary if the possibilites of clinical risk management are to be explored.

    The introduction of clinical risk management is covered in the final chapters, starting with a contribution on ‘essentials’ from Roger Clements, based on his long experience. The chapter on the central issue of incident reporting systems is interestingly covered by a joint presentation which draws from USA and UK experience (by Orley Lindgren and Jonathan Secker-Walker). The final chapters pick up on important issues such as clinical complaints, alternative dispute resolution, support for staff involved in litigation, and a guide for hospital claims managers on what has been one of the most encouraging developments in recent years, namely the better handling of claims by staff with more training and support than before.

    It is right and proper that the editor Charles Vincent’s chapter, on how to care for patients harmed by treatment, is one of the most essential for clinicians to read and consider. Clinical directors could use this chapter and its concluding suggestions as a checklist to see how well their specialties are doing.

    The nearly 600 pages (including some useful appendices) could well be criticised for length, repetitiveness, and variability in the standard of chapters. But if used as intended, as a source of reference and an attempt to provide a comprehensive outline of the current state of the art, it will meet the present needs of many clinicians and managers. In the period since it has been published, important changes have occurred, such as the introduction of the new clinical complaints procedure and the publication of Lord Woolf’s final report on improving access to justice. It is likely that with the speed of these and other changes, a second edition will be necessary quite soon.

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