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- Culture of Safety
- Education and Training 3
- Error Reporting and Analysis 4
- Legal and Policy Approaches 1
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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.
Journal Article > Commentary
Weick KE, Sutcliffe KM. Calif Manage Rev. Winter 2003;45:73-84.
Despite an unacceptably high rate of postoperative mortality, surgeons at the Bristol Royal Infirmary continued to perform pediatric cardiac surgery until the United Kingdom Department of Health intervened. A subsequent inquiry revealed that as many as 35 deaths over a 5-year period could have been prevented, and two surgeons lost their licenses. This analysis explores the deficiencies in safety culture that allowed such poor outcomes to go unaddressed. A prior study also discussed the scandal's implications for hospital quality improvement efforts.
Special or Theme Issue
Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.
Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Journal Article > Commentary
Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.
Kirby J, Cannon C, Darrah L, Milliman-Richard Y. Patient Exp J. 2018;5:76-90.
Parents are important advocates for the safe care of their children. This commentary describes how one hospital built a toolkit to operationalize family members as partners to improve safety. The organization applied high reliability concepts to identify, recognize, and support projects at the hospital to successfully use patients' perspectives to design improvements.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.