Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Moonesinghe SR, Lowery J, Shahi N, et al. BMJ. 2011;342:d1580.
Duty hours for resident physicians in the United States have been limited to 80 hours per week since 2003, but more stringent European regulations now limit trainees to 48 hours on duty each week. This systematic review concurred with another recent review in finding that the American regulations have not negatively impacted trainee or patient outcomes, but found that the impact of European regulations has not been adequately studied.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.
Dublin: Irish Society for Quality and Safety in Healthcare; 2004.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.
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