Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 3
- Human Factors Engineering 2
- Legal and Policy Approaches 2
- Quality Improvement Strategies 3
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 2
- Surgical Complications 1
Search results for ""
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.
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.
Tremlett G. Guardian.co.uk; July 13, 2009.
This newspaper article reports on a family that experienced two medical errors, resulting in the death of both a mother and her infant.
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.
London, England: Teenage Cancer Trust; 2013.
This report spotlights challenges to early diagnosis of cancer in pediatrics and offers guidance for clinicians and families to improve care for these patients.
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.
Leslie I. New Statesman. June 4, 2014.
This magazine article reports on the experience of a pilot whose wife died due to a medical error. In response to learning about the chain of events that led to her death and how it could have been prevented, he committed to applying aviation safety concepts such as crew resource management and human factors to improve health care safety.
Haelo. Harm Free Care. London, UK: National Health Service; 2014.
Anthes E. Nature. 2015;523:516-518.
Checklists have been advocated as a safety strategy, despite challenges that hinder their success. Reporting on the unmet potential of checklists to reliably improve health care safety, this news article describes how resistance to checklist use, design problems, and implementation factors can limit their effectiveness.
O'Loughlin E. New York Times. April 30, 2018.
Large-scale adverse events should lead to system examination and improvement. This newspaper article reports on misread cervical cancer tests that resulted in 208 women receiving false negative results over a 4-year period from a publicly funded smear test program in Ireland and the government inquiry launched in response to this large-scale failure.
Web Resource > Multi-use Website
Farnborough, Hampshire, UK.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.