SIM714. Patient Safety & Quality Improvement. View Online. Wu AW. Medical error: the second victim. BMJ 2000;320: doi: /bmj
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1 SIM714 View Online Patient Safety & Quality Improvement 1 Wu AW. Medical error: the second victim. BMJ 2000;320: doi: /bmj Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Quality & Safety 2012;21: doi: /bmjqs The Breakthrough Series: IHI s Collaborative Model for Achieving Breakthrough Improvement. emodelforachievingbreakthroughimprovement.aspx 4 Vincent C. Patient safety. Chichester, West Sussex: : Wiley-Blackwell oleth 5 Reason JT. The human contribution: unsafe acts, accidents and heroic recoveries. Farnham, UK: : Ashgate /10
2 6 The measurement and monitoring of safety The Health Foundation. 7 More than money: closing the NHS quality gap The Health Foundation. 8 How can leaders influence a safety culture? The Health Foundation. 9 Measuring safety culture The Health Foundation Does improving safety culture affect patient outcomes? The Health Foundation. s 11 Department of Health. Building a safer NHS for patients: Implementing an organisation with a memory. ublications/publicationspolicyandguidance/browsable/dh_ A promise to learn, a commitment to act. wick_report.pdf 2/10
3 13 Building the foundations for improvement The Health Foundation Constructive comfort: accelerating change in the NHS The Health Foundation Taking safety on board: the board s role in patient safety. fety.pdf 16 Personal accountability in healthcare: searching for the right balance. rtherightbalance.pdf 17 A promise to learn - a commitment to act. wick_report.pdf 18 Reducing prescribing errors [ARCHIVED CONTENT] The Report Freedom to Speak Up Review. uk/the-report/ 3/10
4 20 Involving patients in improving safety The Health Foundation What is patient safety culture? A review of the literature. Journal of Nursing Scholarship Published Online First: e=ip,url,shib&db=rzh&an= &site=ehost-live 22 Amalberti R. Five System Barriers to Achieving Ultrasafe Health Care. Annals of Internal Medicine 2005;142. doi: / Sari AB-A, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334 : doi: /bmj ae 24 Amalberti R, Vincent C, Auroy Y, et al. Violations and migrations in health care: a framework for understanding and management. Quality and Safety in Health Care 2006;15 :i doi: /qshc Webster CS. The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals. Anaesthesia 2005;60: doi: /j x 26 Lawton R. Not working to rule: Understanding procedural violations at work. Safety Science 1998;28: doi: /s (97) /10
5 27 Vincent C. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322: doi: /bmj Landrigan CP, Parry GJ, Bones CB, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. New England Journal of Medicine 2010;363: doi: /nejmsa Sammer CE, Lykens K, Singh KP, et al. What is Patient Safety Culture? A Review of the Literature. Journal of Nursing Scholarship 2010;42: doi: /j x 30 Amalberti R. Five System Barriers to Achieving Ultrasafe Health Care. Annals of Internal Medicine 2005;142. doi: / Vincent C. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. BMJ 2000;320: doi: /bmj Lawton R. Barriers to incident reporting in a healthcare system. Quality and Safety in Health Care 2002;11:15 8. doi: /qhc Evans SM. Attitudes and barriers to incident reporting: a collaborative hospital study. Quality and Safety in Health Care 2006;15: doi: /qshc /10
6 34 Barach P. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320: doi: /bmj Panesar SS, Carson-Stevens A, Salvilla SA, et al., editors. Patient safety and healthcare improvement at a glance. Chichester, West Sussex, UK: : John Wiley and Sons, Inc oleth 36 Hollnagel E, Braithwaite J, Wears RL. Resilient health care. Farnham, Surrey, UK England: : Ashgate oleth 37 Resilient Health Care: EBSCOhost. 4e%40sessionmgr4002&crlhashurl=login.aspx%253fdirect%253dtrue%2526AuthType%25 3dip%252curl%252cshib%2526db%253dnlebk%2526AN%253d841921%2526site%253deh ost-live&hid=4106&vid=0&bdata=jkf1dghuexblpwlwlhvybcxzaglijnnpdgu9zwhvc3qtb Gl2ZQ%3d%3d#AN=841921&db=nlebk 38 Provost LP, Murray SK. The health care data guide: learning from data for improvement. 1st ed. San Francisco, CA: : Jossey-Bass oleth 39 Flin RH, Mitchell L. Safer surgery: analysing behaviour in the operating theatre. Farnham, England: : Ashgate /10
7 oleth 40 Hogan SJ, Coote LV. Organizational culture, innovation, and performance: A test of Schein s model. Journal of Business Research 2014;67: doi: /j.jbusres Classen DC, Resar R, Griffin F, et al. Global Trigger Tool Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs 2011;30 : doi: /hlthaff Quality. JAMA 2002;287. doi: /jama jbk Cover Page. Resilient Health Care =841921&site=ehost-live 44 Hartnell N, MacKinnon N, Sketris I, et al. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Quality & Safety 2012;21: doi: /bmjqs Leape LL, Berwick DM, Bates DW. What Practices Will Most Improve Safety? JAMA 2002; 288. doi: /jama De Feijter JM, de Grave WS, Koopmans RP, et al. Informal learning from error in hospitals: 7/10
8 what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. Advances in Health Sciences Education 2013;18: doi: /s Wallace LM, Spurgeon P, Benn J, et al. Improving patient safety incident reporting systems by focusing upon feedback - lessons from English and Welsh trusts. Health Services Management Research 2009;22: doi: /hsmr Brasaite I, Kaunonen M, Suominen T. Healthcare professionals knowledge, attitudes and skills regarding patient safety: a systematic literature review. Scandinavian Journal of Caring Sciences 2015;29: doi: /scs Incidence of Adverse Events and Negligence in Hospitalized Patients. New England Journal of Medicine 1991;325: doi: /nejm Perrow C. Normal accidents: living with high-risk technologies. Basic Books Carthey J. Institutional resilience in healthcare systems. Quality in Health Care 2001;10 : doi: /qhc An introduction to the NHS change model - NHS IQ The Nut Island Effect. 8/10
9 54 Lawton R, O Hara JK, Sheard L, et al. Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes. BMJ Quality & Safety 2015;24: doi: /bmjqs TIM SCOTT. Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care 2003;15 : Cochrane Review Abstracts: the effectiveness of strategies to change culture in healthcare. Canadian Journal of Dental Hygiene Published Online First: htype=ip,url,shib&db=rzh&an= &site=ehost-live 57 Parmelli E, Flodgren G, Beyer F, et al. The effectiveness of strategies to change organisational culture to improve healthcare performance: a systematic review. Implementation Science 2011;6. doi: / Hogan SJ, Coote LV. Organizational culture, innovation, and performance: A test of Schein s model. Journal of Business Research 2014;67: doi: /j.jbusres Kannampallil TG, Schauer GF, Cohen T, et al. Considering complexity in healthcare systems. Journal of Biomedical Informatics 2011;44: doi: /j.jbi /10
10 Shojania KG, Dixon-Woods M. Bad apples : time to redefine as a type of systems problem? BMJ Quality & Safety 2013;22: doi: /bmjqs Reason J. Human error: models and management. BMJ 2000;320: doi: /bmj Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality & Safety 2014;23: doi: /bmjqs RICHER M-C, RITCHIE J, MARCHIONNI C. If we can t do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments. Journal of Nursing Management 2009;17: doi: /j x 64 Bonke B, Zietse R, Norman G, et al. Conscious versus unconscious thinking in the medical domain: the deliberation-without-attention effect examined. Perspectives on Medical Education 2014;3: doi: /s z 65 Carroll JS. Redirecting traditional professional values to support safety: changing organisational culture in health care. Quality and Safety in Health Care 2004;13:ii doi: /qshc /10
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