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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.
Journal Article > Study
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141:e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
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.