Commentary A tragic death: a time to blame or a time to learn? Citation Text: Runciman WB, Merry AF. A tragic death: a time to blame or a time to learn? Qual Saf Health Care. 2003;12(5):321-2. 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 Runciman WB, Merry AF. Qual Saf Health Care. 2003;12(5):321-2. 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: Runciman WB, Merry AF. A tragic death: a time to blame or a time to learn? Qual Saf Health Care. 2003;12(5):321-2. 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Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. March 4, 2009
A new infusion syringe label system designed to reduce task complexity during drug preparation. June 27, 2007
The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial. February 25, 2009
A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. October 30, 2013
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. June 22, 2005
A retrospective audit of postoperative days alive and out of hospital, including before and after implementation of the WHO surgical safety checklist. February 2, 2022
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019
Using FDA reports to inform a classification for health information technology safety problems. March 21, 2012
Measures of patient safety in developing and emerging countries: a review of the literature. March 17, 2010
Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level. November 25, 2015
Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports. December 16, 2015
A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. May 27, 2020
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey. March 25, 2015
Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011. February 11, 2015
Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. February 15, 2012
Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. June 27, 2007
Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey. November 17, 2021
Relationship between tort claims and patient incident reports in the Veterans Health Administration. April 21, 2005
Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008. August 31, 2011
Promoting patient safety through prospective risk identification: example from peri-operative care. March 17, 2010
Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. July 2, 2008
Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting. May 31, 2006
Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia. April 5, 2006
The contribution of labelling to safe medication administration in anaesthetic practice. June 15, 2011
Fake and expired medications in simulation-based education: an underappreciated risk to patient safety. March 23, 2016
Quality improvement in healthcare in New Zealand. Part 2: are our patients safe--and what are we doing about it? August 16, 2006
Criminalisation of unintentional error in healthcare in the UK: a perspective from New Zealand. April 24, 2019
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Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. March 3, 2010
Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York. February 27, 2008
Team management training using crisis resource management results in perceived benefits by healthcare workers. October 24, 2007
Implementation of a mock root cause analysis to provide simulated patient safety training. December 20, 2017
The incidence and preventability of adverse events in older acutely admitted patients: a longitudinal study with 4292 patient records. April 14, 2021
Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system. February 20, 2008
The missing evidence: a systematic review of patients' experiences of adverse events in health care. October 28, 2015
Patients' reports of adverse events: a data linkage study of Australian adults aged 45 years and over. September 6, 2017
A 'paperless' wall-mounted surgical safety checklist with migrated leadership can improve compliance and team engagement. January 27, 2016
Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students. September 21, 2016
Effectiveness of an information technology intervention to improve prophylactic antibacterial use in the postoperative period. March 30, 2011
Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs. August 15, 2012
Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova. April 8, 2015
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Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation. October 5, 2011
Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study. March 24, 2010
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World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. May 23, 2018
5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. September 24, 2014
We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations. March 17, 2021
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. August 18, 2021
Using morbidity and mortality conferences to drive quality improvement and reduce errors. May 17, 2023
Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. May 10, 2023
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"Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing. December 8, 2021
How and when organization identification promotes safety voice among healthcare professionals. October 6, 2021
Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study. May 5, 2021
Nurses' perceptions of open disclosure processes in cancer care: a cross-sectional study. December 16, 2020
Use of an audit with feedback implementation strategy to promote medication error reporting by nurses. November 25, 2020
Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives. June 12, 2019
Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC). May 15, 2019
Criminalisation of unintentional error in healthcare in the UK: a perspective from New Zealand. April 24, 2019
A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people. April 10, 2019
Association between organisational and workplace cultures, and patient outcomes: systematic review. January 17, 2018
Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare. April 19, 2017
A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy. January 14, 2015