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Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.
This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984–1995.
London, England: The Stationery Office; July 2001.
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.
London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.
This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.
Journal Article > Study
Litchfield IJ, Bentham LM, Lilford RJ, Greenfield SM. Fam Pract. 2014;31:592-597.
The communication of test results is a key activity for primary care practices. However, this qualitative study discovered that current systems for communicating test results vary widely across practices and pose many crucial pitfalls, such as the lack of a method for detecting delayed or missing results.
Journal Article > Study
Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.
Tudor Car L, Papachristou N, Bull A, et al. BMC Fam Pract. 2016;17:131.
Compared with other patient safety issues, diagnostic errors have received little attention until recently. Missed or delayed diagnoses are a common reason for malpractice claims. This study sought to determine barriers and solutions to delays in diagnosis in primary care. Investigators sent a questionnaire to more than 500 clinicians and received 113 responses. Participants identified 33 discrete problems associated with delays in diagnosis and suggested 27 solutions. The main issues included inability to meet patients' care needs and inadequate communication between secondary and primary care. The top solutions included improving training of primary care doctors and enhancing communication among providers as well as between providers and patients, especially around test results. An Annual Perspective discussed diagnostic errors in more detail.