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Manchester, UK: General Medical Council; June 2019.
Finding the appropriate balance between assigning criminality and accountability for tragic preventable patient harm is difficult. Summarizing a high-profile case in the United Kingdom that involved the death of a pediatric patient, misdiagnosis, and a senior pediatric trainee, this report explores elements of the criminality and accountability debate across the system and discusses policy, judicial, and individual components of a fair and just response to adverse events to keep organizations, clinicians, and patients safe.
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.
Communicating Radiation Risks in Paediatric Imaging: Information to Support Healthcare Discussions About Benefit and Risk.
Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241510349.
Overuse of diagnostic imaging poses patient safety hazards, particularly for children. This report reviews techniques clinicians can use to discuss risks associated with using radiologic procedures with parents of pediatric patients. The publication includes answers to common questions about various types of tests and tips for enhancing conversations with parents.
Addressing the Global Shortages of Medicines, and the Safety and Accessibility of Children's Medication.
Geneva, Switzerland: World Health Organization; 2015.
Drug shortages have the ability to affect the patient safety in emergency departments, oncology services, and pediatrics. This report discusses the consequences of drug shortages, approaches different countries are taking to reduce their occurrence, and strategies such as proactive identification of potential supply limitations and collective agreements to manage shortages.
Improving Diagnosis: Teenage Cancer Trust Report on Improving the Diagnostic Experience of Young People With Cancer.
London, England: Teenage Cancer Trust; 2013.
This report spotlights challenges to early diagnosis of cancer in pediatrics and offers guidance for clinicians and families to improve care for these patients.
London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.
Analyzing research and more than 900,000 incident reports submitted to the National Patient Safety Agency, this report identifies adverse events affecting children and emphasizes actions for stakeholders to enhance safety for pediatric patients in the United Kingdom.
Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
This report suggests that a systems approach to child social services in Great Britain would facilitate a fair and open culture and encourage learning from near misses.
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.