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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.
Abelson R. New York Times. May 17, 2007;Business section:1.
This article reports on a Pennsylvania hospital system that offers a flat fee for bypass surgery and a guarantee for follow-up care should complications arise.
Journal Article > Study
Becker DJ. Health Serv Res. 2007;42:1589-1612.
Prior research has demonstrated that patients admitted to the hospital on a weekend have a higher risk of mortality from conditions requiring emergency treatment and may experience a higher rate of preventable complications. These problems have been attributed to lower hospital staffing ratios on weekends. This article specifically evaluated the quality of care provided to patients hospitalized with acute myocardial infarction (AMI) and found that patients admitted on weekends were significantly less likely to undergo invasive treatments (such as cardiac catheterization or bypass surgery) within the first day of admission. This finding corroborates another recent study, which also found a lower rate of invasive procedure use among AMI patients admitted on the weekend, and also demonstrated increased mortality among those patients. Taken together, these results suggest that both increased staffing and incentives to perform weekend procedures may be needed to counteract the "weekend effect."
Carbonara P. Fast Company. October 2008.
This magazine article describes how one health system is using an evidence-based, pay-for-performance program to reduce errors and improve outcomes in coronary-artery bypass graft (CABG) surgery.
Kowalczyk L. Boston Globe. April 17, 2009;Metro:1.
This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery program following errors that caused serious complications for two infants.
Journal Article > Commentary
Cassidy J. BMJ. 2009;339:b2693.
This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.