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Wong J, Beglaryan H. Toronto, Ontario: The Change Foundation; February 2004.
A literature review of preventable adverse events in acute-care hospitals. Full analysis and recommendations are provided based on the research findings and input from an expert panel.
Sagan SD. Princeton, NJ: Princeton University Press; 1993.
Two competing paradigms dominate the study of the hazards associated with complex organizations. The more optimistic of these paradigms, high-reliability theory, focuses on organizations that have achieved exemplary safety records and identifies key factors contributing to these records, including a high priority for safety within the organization, significant levels of redundancy, decentralization of authority, and organizational learning. Normal accident theory takes a more pessimistic view by asserting that, with a certain degree of complexity and when processes are time dependent and tightly coupled, major accidents become almost inevitable. In fact, redundancy, decentralized decision making, and many specific safety measures may only increase the degree to which actions in one part of the system can produce unexpected, baffling effects in other parts of the system. Sagan sets out to test these two competing theories by answering the question: why has there never been an accidental nuclear war? The results of Sagan's detailed archival research initially appear to confirm the predictions of high-reliability theory. However, interviews with key personnel uncover several hair-raising near misses during the Cuban missile crisis. In fact, Sagan ultimately concludes that good fortune played a greater role than good design in the safety record of the nuclear weapons industry to date.
Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
This report suggests that a systems approach to child social services in Great Britain would facilitate a fair and open culture and encourage learning from near misses.
Journal Article > Commentary
Pauker SG, Zane EM, Salem DN. JAMA. 2005;294:2906-2908.
This editorial builds on the discussion from a study suggesting that overall improvement in the adoption and implementation of patient safety systems is slow. The authors offer a series of explanations for these delays in important improvements and apply the concept called the "theory of constraints." This theory asks the question of what should change, to what should it change, and how should change occur. Responses are framed with discussion of six thought processes that must occur at an organization for change to become possible. These include agreement that a problem exists, agreement that a proposed solution actually solves the problem, and identifying obstacles and how they can be overcome. The authors argue that sustained change occurs only when these root causes receive appropriate exploration and direct action in fostering improved safety systems.
Vaitheeswaran V. Economist. April 16, 2009;Special Report:6-8.
This article explores how information technology and smart software could potentially improve quality and reduce medical errors.
Journal Article > Study
Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes.
Burnett S, Benn J, Pinto A, Parand A, Iskander S, Vincent C. Qual Saf Health Care. 2010;19:313-317.
Implementation of large-scale safety improvement programs requires learning organizations—organizations with the capacity for change. The Safer Patients Initiative was implemented at four United Kingdom sites in 2004 in collaboration with the Institute for Healthcare Improvement with the goal of reducing preventable harm. This qualitative study evaluated the readiness of each organization to undertake this initiative, and found that a positive safety culture, a history of organizational leadership and involvement in safety initiatives, and availability of information technology for quality measurement were important predictors of successful implementation. The importance of strong organizational leadership in improving safety was recognized by The Joint Commission in a Sentinel Event Alert.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.
Journal Article > Commentary
Accountability, organisational learning and risks to patient safety in England: conflict or compromise?
Dodds A, Kodate N. Health Risk Soc. 2011;13:327-346.
This commentary explores risk regulation in the English National Health Service and describes its two approaches for patient safety policies.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Patient Safety Learning: London, UK; September 2018.
This paper provides an analysis of the current status of patient safety in the United Kingdom. The report outlines existing challenges and strategies to drive system improvement, including leadership engagement, shared learning, patient safety data optimization, and building on expertise from other high-risk industries.