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 An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review. December 8, 2021 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 Locum doctor working and quality and safety: a qualitative study in English primary and secondary care. June 5, 2024 The top patient safety strategies that can be encouraged for adoption now. March 13, 2013 Advancing the science of patient safety. May 25, 2011 Learning from litigation. The role of claims analysis in patient safety. 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A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. April 25, 2007
An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review. December 8, 2021
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
Locum doctor working and quality and safety: a qualitative study in English primary and secondary care. June 5, 2024
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013
Potential medical adverse events associated with death: a forensic pathology perspective. January 6, 2010
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. March 1, 2023
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS). June 26, 2019
Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals. October 17, 2018
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A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009
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Evaluating the prevalence of four recommended practices for suicide prevention following hospital discharge. July 10, 2024
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Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action. September 21, 2022
What's going well: a qualitative analysis of positive patient and family feedback in the context of the diagnostic process. March 6, 2024
Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023
Three missed critical nursing care processes on labor and delivery units during the COVID-19 pandemic. May 31, 2023
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19. July 5, 2023
Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. January 13, 2021
A multisite study of interprofessional teamwork and collaboration on general medical services. November 25, 2020
Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department. October 14, 2020
Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review. June 30, 2021
Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care. October 27, 2021
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020
Cumulative effect of flexible duty-hour policies on resident outcomes: long-term follow-up results from the FIRST trial. July 15, 2020
Moving toward improved teamwork in cancer care: the role of psychological safety in team communication. December 14, 2016
Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review. December 7, 2016
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important? August 31, 2016
A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India. March 26, 2014
SBAR improves nurse–physician communication and reduces unexpected death: a pre and post intervention study. October 23, 2013
Public perceptions and preferences for patient notification after an unsafe injection. March 13, 2013
Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems. August 1, 2012
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012
Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events. October 24, 2012
Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial. June 8, 2016
Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey. October 14, 2015
Connecting patients and clinicians: the anticipated effects of Open Notes on patient safety and quality of care. August 5, 2015
Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. April 8, 2020
Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital. February 12, 2020
High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. July 31, 2019
The impact of computerised physician order entry and clinical decision support on pharmacist–physician communication in the hospital setting: a qualitative study. February 27, 2019
Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020
Facilitated self-reported anaesthetic medication errors before and after implementation of a safety bundle and barcode-based safety system. February 13, 2019
A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life. February 2, 2011
Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008
Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories. March 12, 2008
The effect of drug concentration expression on epinephrine dosing errors: a randomized trial. January 16, 2008
Using the rapid response system to provide better oversight of patient care processes. November 14, 2007
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006
Potential role of pharmacogenomics in reducing adverse drug reactions: a systematic review. August 31, 2005
Hospital rules-based system: the next generation of medical informatics for patient safety. April 15, 2005
Patient safety curriculum for surgical residency programs: results of a national consensus conference. April 11, 2007
Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns. November 3, 2010
Mobile in situ obstetric emergency simulation and teamwork training to improve maternal–fetal safety in hospitals. September 29, 2010
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. May 5, 2010
The culture of safety: results of an organization-wide survey in 15 California hospitals. March 6, 2005
Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. April 29, 2009
Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation. April 20, 2022
Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes. April 13, 2022
Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events. April 6, 2022
Patient Safety Innovations eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. April 7, 2022
Systems approach to suicide prevention: strengthening culture, practice, and education. June 28, 2023
Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient. February 2, 2022
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