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.
Hughes J. BBC News. August 12, 2010.
This article reveals how the majority of hospitals have not acted on British National Health Services (NHS) safety alerts.
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
London, UK: The Health Foundation; January 2013.
This review analyzes research on engaging patients in safety improvement and details which strategies are most effective.
Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.
Keogh B. London, UK: National Health Service; July 2013.
Outlining findings from an investigation into care delivered at National Health Service trusts with high mortality rates, this report details weaknesses in the organizations and recommends actions to address them.
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.
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.