Journal Article
Commentary

When things go wrong: how health care organizations deal with major failures.

Walshe K, Shortell SM. Health affairs (Project Hope). 2004;23:103-11.

The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.