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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 > Study
Agency for Healthcare Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse outcomes?
Rhee D, Zhang Y, Papandria D, Ortega G, Abdullah F. J Pediatr Surg. 2012;47:107-111.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) are widely used to screen administrative data for evidence of adverse events in adult inpatients. The Pediatric Quality Indicators (PDIs) aim to fill the same role for pediatric hospitals, and this study provides strong evidence that they can identify patients who experience preventable harm. Evaluation of nearly 2 million pediatric discharges over a 20-year period found that patients who experienced one PDI had a 20% increased risk of mortality. The PDIs include postoperative complications such as respiratory failure, a case of which is discussed vividly in this AHRQ WebM&M commentary.