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- Just Culture
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.
Journal Article > Commentary
Yee PL, Edwards ML, Dixon J, Gleason NS. Nurs Adm Q. 2009;33:48-53.
This article discusses how one children's hospital used patient safety rounds to identify 191 issues in its first year and then took measures to resolve them.