Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
Approach to Improving Safety
- Error Analysis
- Communication between Providers
- Provider-Patient Communication
- Culture of Safety
- Education and Training
Setting of Care
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.