Commentary Understanding and learning from organisational failure. Citation Text: Walshe K. Understanding and learning from organisational failure. Qual Saf Health Care. 2003;12(2):81-2. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Walshe K. Qual Saf Health Care. 2003;12(2):81-2. View more articles from the same authors. PubMed citation Available at Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Walshe K. Understanding and learning from organisational failure. Qual Saf Health Care. 2003;12(2):81-2. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. April 25, 2007 Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. March 12, 2008 How to avoid paediatric medication errors: a user's guide to the literature. July 6, 2005 Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories. November 12, 2008 Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. August 16, 2006 Smart pumps improve medication safety but increase alert burden in neonatal care December 4, 2019 Independent double-checks for high-alert medications: essential practice. 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A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. April 25, 2007
Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. March 12, 2008
Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. August 16, 2006
Modification of potentially inappropriate prescribing following fall-related hospitalizations in older adults. July 10, 2019
Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy. July 18, 2007
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery? November 17, 2010
Lifetime prevalence and correlates of patient-perceived medical errors experienced in the U.S. ambulatory setting: a population-based study. November 18, 2020
Misuse of pediatric medications and parent–physician communication: an interactive voice response intervention. April 12, 2017
A systematic review of primary care safety climate survey instruments: their origins, psychometric properties, quality, and usage. June 13, 2018
Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies. September 9, 2020
Barriers and facilitators of adverse event reporting by adolescent patients and their families. March 29, 2017
Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review. June 25, 2014
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department. October 22, 2008
Significant and sustained reduction in chemotherapy errors through improvement science. April 5, 2017
Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice. December 1, 2021
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes. July 29, 2015
Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers. June 27, 2018
Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis. August 2, 2023
Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events. September 6, 2023
Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study. May 10, 2023
The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study. February 8, 2017
Potential medical adverse events associated with death: a forensic pathology perspective. January 6, 2010
Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study. November 7, 2012
Effect of day of the week on short- and long-term mortality after emergency general surgery. April 5, 2017
Using the rapid response system to provide better oversight of patient care processes. November 14, 2007
Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. December 19, 2007
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Revisiting duty-hour limits — IOM recommendations for patient safety and resident education. December 10, 2008
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. March 6, 2005
Inter-rater reliability of a classification system for hospital adverse drug event reports. September 12, 2007
SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study. October 23, 2013
Evaluation of communication and safety behaviors during hospital-wide code response simulation. March 2, 2022
Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. March 10, 2010
Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey. October 14, 2015
A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India. March 26, 2014
'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns. June 11, 2014
Effect of computer order entry on prevention of serious medication errors in hospitalized children. March 19, 2008
Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review. August 31, 2005
Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety. January 23, 2013
Can patients report patient safety incidents in a hospital setting? A systematic review. May 23, 2012
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Towards safer healthcare: qualitative insights from a process view of organisational learning from failure. August 25, 2021
To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021
Learning from safety incidents in high reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare. March 31, 2021
Health professionals' perspectives of safety issues in mental health services: a qualitative study. March 31, 2021
Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning. January 27, 2021
It’s time to consider national culture when designing team training initiatives in healthcare. January 27, 2021
Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments. October 7, 2020
COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada. September 30, 2020
Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. May 13, 2020
Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence. February 26, 2020
The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes. July 10, 2019