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Journal Article > Commentary
Feder HM. J Health Care Compliance. May/June 2006;8:49-50, 80.
This article briefly discusses the role of patient safety organizations (PSOs) as stipulated by the Patient Safety and Quality Improvement Act of 2005 and issues related to privacy, confidentiality, and impact on state reporting systems.
Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.
Journal Article > Study
The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.
Currie G, Waring J, Finn R. Public Admin. 2008;86:363-385.
This article analyzes the implementation of the United Kingdom's error reporting system, the National Reporting and Learning System, and addresses the cultural conflicts between physicians, nurses, and managers inherent in implementing such a system.
Jefferson City, MO: Center for Patient Safety; June 11, 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report analyzes trends present in reports submitted to the PSO in 2018. Medication errors, falls, and health care–acquired infections were frequently reported. The material discusses reasons for these events, shares lessons learned, and points to resources to aid organizations in reducing conditions that enable reportable occurrences.
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
The Francis inquiry uncovered numerous problems in the National Health Service and led to many commentaries about improvement strategies. Summarizing achievements in applying recommendations following the inquiry, this report outlines where further work is needed to ensure that advances in safe care delivery are sustained. Companion materials available include an analysis exploring equality considerations and a table revealing the government response and progress for each of the 290 recommendations put forth in the original inquiry.