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Search results for "Book/Report"
- Near Miss
Heilman J, ed. Albuquerque, NM: University of New Mexico; May 2013.
Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012.
Retford, Notts, UK: NHS Alliance; 2011.
This publication discusses an initiative to monitor errors and near misses in after-hours care in the United Kingdom and reviews lessons learned during its first year of implementation.
Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158.
Close calls (sometimes called near misses) pose unique challenges and opportunities when it comes to learning from mistakes. Because they are less dramatic than errors that lead to harm, they tend to be ignored in most institutional reporting systems. With a foreword by safety pioneer James Reason, this multiauthored book makes the case that close calls—which are significantly more common than true adverse events—can provide a unique window into an organization's safety hazards. Moreover, because there is less fear about liability and less shame associated with close calls, they may be easier for clinicians to talk about and learn from than true adverse events. By providing case studies from a variety of areas of medicine, this book illustrates the important role of close call reporting, education, and analysis in a robust safety program.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.
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.