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- Communication Improvement 2
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- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 1
- Transparency and Accountability 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators 8
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Search results for "Narrative/Storytelling"
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.
Hatch S. New York, NY: Basic Books; 2016. ISBN: 9780465050642.
Cardiff, UK: NHS Wales; April 2010.
This report provides insights from participants in the 1000 Lives Campaign on how patient stories can focus attention on safety improvements and drive commitment to change.
Casey SM. Santa Barbara, CA: Aegean Publishing Company; 1998. ISBN 13: 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
Klein G. Cambridge, MA: MIT Press; 1998.
Davenport TH, Prusak L. Boston, MA: Harvard Business School Press; 1998. ISBN: 0875846556.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews.
Mannion R, Blenkinsopp J, Powell M, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2018.
Staff willingness to speak up about safety and process concerns enables organization and practice improvements that prevent patient harm. This review explores challenges to raising concerns in the National Health Service and discusses policies that support whistleblowers. Further research is needed to examine organizational failures when concerns are reported.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.
Manchester, UK: General Medical Council; November 2014.
National Patient Safety Agency, the Medical Defence Union and Medical Protection Society. London, England: NPSA; 2005
This two-part report focuses on the experience of committing a medical error, along with strategies to reduce future events. The first part provides a series of shared stories from clinicians who discuss their personal experiences in making medical errors. The second part uses six case studies of errors as a background for expert analysis and discussion. The report also provides a motivation for reporting by explaining the benefits that come from such vigilance and how changing systems can lead to improved safety.
US Government Accountability Office. Washington, DC: US Government Accountability Office; 2004. Publication GAO-05-83.
The Government Accountability Office studied patient safety programs at four Department of Veterans Affairs (VA) health facilities and recommends that the VA emphasize leadership action and open communication to support safety improvement.
Berntsen KJ. Westport, CT: Praeger; 2004. ISBN: 0275982300.
The author provides an introduction to issues affecting safety in health care for a consumer audience. The text is interspersed with relevant stories from patients and tips to minimize opportunities for failure.
Bogner MS, ed. Mahwah, NJ: Lawrence Erlbaum Associates; 2004. ISBN: 0805833781.