Scandal as a sentinel event—recognizing hidden cost–quality trade-offs. | PSNet

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Commentary

Scandal as a sentinel event—recognizing hidden cost–quality trade-offs.

April 6, 2016

Bloche G. N Engl J Med. 2016;374(11):1001-3.

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Latent factors are known to contribute to system-level failures. This commentary discusses the Mid Staffordshire NHS Foundation Trust inquiry and the Veterans Affairs health system investigation as examples of how executive expectations to meet performance targets and insufficient safety culture led to unintended consequences and system failures.

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