Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 3
- Legal and Policy Approaches
- Quality Improvement Strategies 1
Search results for ""
Dyer C. BMJ. 2005;330:1228.
This article reports on the National Health Service's plan to handle small claims from medical mistakes without litigation.
Morris S. Guardian. February 13, 2007.
This story reports on an investigation into the death of an infant after heart surgery.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
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.
Donaldson L. BBC News. Feb 26, 2009.
This article explores the importance of apology, its benefits, and some barriers to its expression in health care.
Journal Article > Study
High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.
Laverty AA, Smith PC, Pape UJ, Mears A, Wachter RM, Millett C. Health Aff (Millwood). 2012;31:593-601.
While medical errors continue to affect patients on a daily basis, most organizations fear high-profile cases that land on front pages of newspapers or lead to extensive regulatory intervention. This study evaluated the role of England's Care Quality Commission in their own regulatory investigation of major issues occurring in three hospitals. The investigations led to considerable media attention, but whether this influenced patient behavior was unknown. The authors found that the investigations had zero impact on utilization at two of the hospitals. The third experienced a decrease in inpatient admissions and new patient visits, but the effect dissipated 6 months following the public report. In an era of greater transparency and increased attention on patient safety, these findings suggest that patients' decision-making is perhaps less influenced than expected by such events. Two past AHRQ WebM&M perspectives discussed organizational change in the face of highly public errors at Duke and the Dana Farber Cancer Institute.
Hughes J. BBC News. August 12, 2010.
This article reveals how the majority of hospitals have not acted on British National Health Services (NHS) safety alerts.
Department of Health. London, England: Crown Publishing; November 2013. ISBN: 9780101875424.
This report outlines actions that health care leaders in the United Kingdom have committed to take in order to address system problems identified by an inquiry into Mid Staffordshire National Health Services Foundation Trust.
Harrow, Middlesex, UK: The Patients Association; 2013.
This publication provides patient and family accounts of incidents involving inadequate care or harm and highlights the need for improvements recommended in a National Health Services report.
Kremer W. BBC News Magazine. July 6, 2014.
This magazine article reports how weaknesses in physician understanding of statistics can lead to poorly informed discussions with patients about risks and treatment options. Using actual numbers instead of percentages may help prevent confusion.