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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.
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.
Journal Article > Commentary
Macrae C. BMJ Qual Saf. 2014;23;440-445.
This commentary examines how minor risks, when propagated and not addressed, may result in organizational disasters, as evidenced in the Francis report. The author advocates for early detection of workarounds and routine investigations into system causes of errors to reveal latent safety hazards in health care.