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Journal Article > Commentary
Duthie EA. Nurs Manage. 2018;49:18-21.
A just culture balances organizational context with appropriate accountability after an error. This commentary illustrates the difference between blame and accountability as applied to a near miss. The author highlights how accountability enables individual and organizational learning through constructive examination of error.
Journal Article > Study
Drach-Zahavy A, Pud D. J Adv Nurs. 2010;66:794-805.
This study evaluated the mechanisms by which hospital wards learned from medication administration errors and the effect these learning strategies had on subsequent incidence of errors.
Eid KA. Nursing. 2015;45:14-16.
Robust processes that enable review and analysis of medical errors are critical to support organizational learning. This commentary highlights one institution's experience convening a multidisciplinary committee focused on improving medication administration through analysis of medication-related incidents and implementing interventions based on the group's findings.
In: On the State of the Public Health: Annual Report of the Chief Medical Officer 2004. London, England: Department of Health; 2005.
This chapter analyzes compliance with National Health Service patient safety alerts, as outlined in An Organization with a Memory, in four risk areas and makes recommendations for improving compliance.