Narrow Results Clear All
- Communication Improvement 16
- Culture of Safety 9
- Education and Training 6
- Error Reporting and Analysis 23
- Human Factors Engineering 5
- Legal and Policy Approaches 10
- Logistical Approaches 1
- Quality Improvement Strategies 12
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 7
- Device-related Complications 1
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 5
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 3
- Internal Medicine 17
- Pharmacy 1
- Family Members and Caregivers 5
- Health Care Executives and Administrators 33
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 3
Search results for ""
Web Resource > Multi-use Website
44 High Street, Croydon, Surrey, CR0 1YB.
Action against Medical Accidents (AvMA) is an independent United Kingdom charity that promotes better patient safety and justice for individuals affected by a medical incident.
Web Resource > Multi-use Website
4-8 Maple Street, London, W1T 5HD.
The National Patient Safety Agency was created in 2001 to coordinate efforts across the United Kingdom in reporting and learning from mistakes and problems. In April 2016, the agency was folded into the new health care improvement arm of the National Health Service: NHS Improvement.
Dyer C. BMJ. 2005;330:1228.
This article reports on the National Health Service's plan to handle small claims from medical mistakes without litigation.
Journal Article > Study
Stewart D, Helms P, McCaig D, Bond C, McLay J. Br J Clin Pharmacol. 2005;59:677-683.
The investigators issued questionnaires to parents in seven community pharmacies to prospectively monitor pediatric adverse drug reactions (ADRs). They found that the system was effective for reporting ADRs.
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.
Journal Article > Commentary
Entwistle VA, Mello MM, Brennan TA. Jt Comm J Qual Patient Saf. 2005;31:483-494.
Several of the major safety-related organizations (including Agency for Healthcare Research and Quality) have developed brochures telling patients what they can do to avoid errors in their care. The authors of this study reviewed the five primary patient safety brochures and interviewed their developers (and other key stakeholders). Although the brochures have value, they found that recommendations were generally unsupported by evidence, that there was little practical support given to patients regarding how to carry out the recommended actions, and that some of the shifting of responsibility for safety from providers and/or institutions to patients was "inappropriate." They recommend additional research in this area and more attention to "practical facilitation of patient involvement."
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.
Gray R. Scotland on Sunday. January 8, 2006.
This story discusses the impact of a computer glitch in a system used by more than 80% of general practitioners in Scotland. In addition to physician notes being inadvertently attached to the wrong patient's medical record, reports suggest that some patients actually received incorrect prescriptions due to printing errors caused by the system.
Edozien L. Saferhealthcare. June 2, 2006.
This article discusses how misidentification can occur in the medical environment and provides several illustrations of its negative consequences.
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.
Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.
This report, the second in a series from the United Kingdom's National Patient Safety Agency, analyzes nearly 45,000 patient safety incidents relating to mental health that were reported to a nationwide incident reporting system. The majority of reported incidents were from inpatient mental health facilities, primarily involving patient accidents (including falls), disruptive or aggressive behavior, self-harming behavior, and missing (absconding) patients. The report summarizes existing initiatives to improve patient safety in mental health, makes specific recommendations for mental health providers, and identifies priority areas for future research.
National Patient Safety Agency. London, UK: National Health Service.
These documents summarize National Patient Safety Agency incident reporting data from the first year of data collection. They are accompanied by workbooks for data review, slide sets and trends analysis.
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.
Carruthers I, Phillip P. London, UK: National Patient Safety Agency; 2006.
This report reviews the challenges of patient safety efforts of the National Health Service and provides recommendations to further improve health care safety.
Gledhill V. The Evening Chronicle. January 25, 2007;News section:9.
This article reports on a patient death caused by medical omission and the communication failures that occurred with both the family and regulatory body after the incident.
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.