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PSNet: Patient Safety Network
Journal Article

Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.

Weick KE; Sutcliffe KM.

Despite an unacceptably high rate of postoperative mortality, surgeons at the Bristol Royal Infirmary continued to perform pediatric cardiac surgery until the United Kingdom Department of Health intervened. A subsequent inquiry revealed that as many as 35 deaths over a 5-year period could have been prevented, and two surgeons lost their licenses. This analysis explores the deficiencies in safety culture that allowed such poor outcomes to go unaddressed. A prior study also discussed the scandal’s implications for hospital quality improvement efforts.