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London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Journal Article > Study
'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns.
Schwappach DL, Gehring K. BMJ Open. 2014;4:e004740.
Using semistructured interviews with experienced oncology nurses and doctors, this study found that staff were willing to speak up regarding medication safety, but they were not as comfortable voicing concerns related to hygiene and safety rule violations. In these circumstances, staff frequently relied on non-verbal gestures, such as handing the physician gloves.