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Book/Report

Opening the Door to Change. NHS Safety Culture and the Need for Transformation.

Newcastle upon Tyne, UK: Care Quality Commission; December 2018.

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January 23, 2019
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.

The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.

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Newcastle upon Tyne, UK: Care Quality Commission; December 2018.

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