Narrow Results Clear All
- Communication Improvement 11
- Culture of Safety 6
- Education and Training 4
- Error Reporting and Analysis 14
- Human Factors Engineering 4
- Legal and Policy Approaches 8
- Quality Improvement Strategies 7
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 3
- Medical Complications 2
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 3
- Internal Medicine 16
- Family Members and Caregivers 5
- Health Care Executives and Administrators 20
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 1
Search results for ""
Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.
Created in 2001 to institute changes in health care across the United Kingdom, the National Patient Safety Agency (NPSA) presents their first report of patient safety incidents. The two-part report begins with a general discussion of incident reporting, the basis for a national reporting system, and the development of the Patient Safety Observatory. The second part builds on this framework by discussing how the acquired data can be used and translated into safer health care strategies. The report itself encompasses more than 85,000 collected incident reports with analysis, comparisons, and case studies to illustrate important safety issues for future efforts. This represents the first of a series of expected reports from NPSA on patient safety data to be published.
BBC News. August 9, 2005.
This article reports on a prototype electronic wristband that checks medications against a patient's prescription.
Dublin, Ireland: Irish Society for Quality & Safety in Healthcare; 2005.
This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.
Oakeshott I. The Sunday Times. June 18, 2006.
This article reports on incidents of wrong drug and wrong route administration of epidurals in the United Kingdom's National Health Service.
BBC News. August 11, 2006.
This story reports findings from the UK Healthcare Commission's assessment of medication error in the National Health Service. The story is accompanied by an audiovisual news report.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
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.
Legislation/Regulation > Government Resource
Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.
This notice highlights the importance of standardizing wristband design and information to make their use consistent for every patient in the United Kingdom.
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.
The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.
This publication summarizes the results of a United Kingdom hospital survey that identified strengths and weaknesses in National Health Service efforts to support organizational patient safety commitment and improvement. The report closes with suggestions to support board-level engagement in this work.
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.
Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.
This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiveness, and patient experiences and found wide variation in the scores.
Journal Article > Study
Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies.
Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Health Expect. 2013;16:e164-e176.
An educational intervention increased the likelihood that patients would participate in safety behaviors, such as asking providers about hand hygiene. Proposed roles for patients in patient safety are discussed in more detail in this Patient Safety Primer.
Journal Article > Review
Davis RE, Sevdalis N, Jacklin R, Vincent CA. J Patient Saf. 2012;8:36-43.
The Joint Commission established engagement of patients in safety as a National Patient Safety Goal in 2007. Organizations have made various efforts to include patients in safety programs, with mixed results. This thematic review uses the example of patients undergoing surgery to establish a framework for the roles patients can play in ensuring their own safety. In this framework, safety-related behaviors can be classified according to the type of error being prevented, the specific action the patient must undertake (e.g., asking questions), and the characteristics of the action. The article also discusses the barriers that can limit patient involvement. One of the study authors, Prof. Charles Vincent, previously authored a seminal article that was among the first to call for integrating patients into safety activities.
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.
St Andrews, Scotland: Scottish Information Commissioner; February 21, 2012. Reference No: 201100433.
This report describes an investigation into a 5-year delay in action plans for critical incident reviews in Scotland.
Journal Article > Study
Pinto A, Faiz O, Vincent C. BMJ Qual Saf. 2012;21:1001-1008.
This study explored current practices related to the National Health Services' being open policy for communicating unintentional harm with patients and families.