SIM714. Patient Safety & Quality Improvement. View Online. Wu AW. Medical error: the second victim. BMJ 2000;320: doi: /bmj

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SIM714 View Online Patient Safety & Quality Improvement 1 Wu AW. Medical error: the second victim. BMJ 2000;320:726 7. doi:10.1136/bmj.320.7237.726 2 Wu AW, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Quality & Safety 2012;21:267 70. doi:10.1136/bmjqs-2011-000605 3 The Breakthrough Series: IHI s Collaborative Model for Achieving Breakthrough Improvement. http://www.ihi.org/resources/pages/ihiwhitepapers/thebreakthroughseriesihiscollaborativ emodelforachievingbreakthroughimprovement.aspx 4 Vincent C. Patient safety. Chichester, West Sussex: : Wiley-Blackwell 2010. http://lib.myilibrary.com?id=382661&entityid=https://shibboleth.plymouth.ac.uk/idp/shibb oleth 5 Reason JT. The human contribution: unsafe acts, accidents and heroic recoveries. Farnham, UK: : Ashgate 2008. http://www.loc.gov/catdir/toc/ecip0828/2008038859.html 1/10

6 The measurement and monitoring of safety The Health Foundation. http://www.health.org.uk/publication/measurement-and-monitoring-safety 7 More than money: closing the NHS quality gap The Health Foundation. http://www.health.org.uk/publication/more-money-closing-nhs-quality-gap 8 How can leaders influence a safety culture? The Health Foundation. http://www.health.org.uk/publication/how-can-leaders-influence-safety-culture 9 Measuring safety culture The Health Foundation. http://www.health.org.uk/publication/measuring-safety-culture 10 Does improving safety culture affect patient outcomes? The Health Foundation. http://www.health.org.uk/publication/does-improving-safety-culture-affect-patient-outcome s 11 Department of Health. Building a safer NHS for patients: Implementing an organisation with a memory. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/p ublications/publicationspolicyandguidance/browsable/dh_4097460 12 A promise to learn, a commitment to act. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/ber wick_report.pdf 2/10

13 Building the foundations for improvement The Health Foundation. http://www.health.org.uk/publication/building-foundations-improvement 14 Constructive comfort: accelerating change in the NHS The Health Foundation. http://www.health.org.uk/publication/constructive-comfort-accelerating-change-nhs 15 Taking safety on board: the board s role in patient safety. http://www.health.org.uk/sites/default/files/takingsafetyonboardtheboardsroleinpatientsa fety.pdf 16 Personal accountability in healthcare: searching for the right balance. http://www.health.org.uk/sites/default/files/personalaccountabilityinhealthcaresearchingfo rtherightbalance.pdf 17 A promise to learn - a commitment to act. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/ber wick_report.pdf 18 Reducing prescribing errors. http://www.health.org.uk/sites/default/files/reducingprescribingerrors.pdf 19 [ARCHIVED CONTENT] The Report Freedom to Speak Up Review. http://webarchive.nationalarchives.gov.uk/20150218150343/http://freedomtospeakup.org. uk/the-report/ 3/10

20 Involving patients in improving safety The Health Foundation. http://www.health.org.uk/publication/involving-patients-improving-safety 21 What is patient safety culture? A review of the literature. Journal of Nursing Scholarship Published Online First: 2010.http://search.ebscohost.com.plymouth.idm.oclc.org/login.aspx?direct=true&AuthTyp e=ip,url,shib&db=rzh&an=2010684976&site=ehost-live 22 Amalberti R. Five System Barriers to Achieving Ultrasafe Health Care. Annals of Internal Medicine 2005;142. doi:10.7326/0003-4819-142-9-200505030-00012 23 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 :79 79. doi:10.1136/bmj.39031.507153.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 :i66 71. doi:10.1136/qshc.2005.015982 25 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;60:1115 22. doi:10.1111/j.1365-2044.2005.04301.x 26 Lawton R. Not working to rule: Understanding procedural violations at work. Safety Science 1998;28:77 95. doi:10.1016/s0925-7535(97)00073-8 4/10

27 Vincent C. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517 9. doi:10.1136/bmj.322.7285.517 28 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;363:2124 34. doi:10.1056/nejmsa1004404 29 Sammer CE, Lykens K, Singh KP, et al. What is Patient Safety Culture? A Review of the Literature. Journal of Nursing Scholarship 2010;42:156 65. doi:10.1111/j.1547-5069.2009.01330.x 30 Amalberti R. Five System Barriers to Achieving Ultrasafe Health Care. Annals of Internal Medicine 2005;142. doi:10.7326/0003-4819-142-9-200505030-00012 31 Vincent C. How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol. BMJ 2000;320:777 81. doi:10.1136/bmj.320.7237.777 32 Lawton R. Barriers to incident reporting in a healthcare system. Quality and Safety in Health Care 2002;11:15 8. doi:10.1136/qhc.11.1.15 33 Evans SM. Attitudes and barriers to incident reporting: a collaborative hospital study. Quality and Safety in Health Care 2006;15:39 43. doi:10.1136/qshc.2004.012559 5/10

34 Barach P. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759 63. doi:10.1136/bmj.320.7237.759 35 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 2014. http://lib.myilibrary.com?id=622056&entityid=https://shibboleth.plymouth.ac.uk/idp/shibb oleth 36 Hollnagel E, Braithwaite J, Wears RL. Resilient health care. Farnham, Surrey, UK England: : Ashgate 2013. http://lib.myilibrary.com?id=523771&entityid=https://shibboleth.plymouth.ac.uk/idp/shibb oleth 37 Resilient Health Care: EBSCOhost. http://web.a.ebscohost.com/ehost/detail/detail?sid=5c0899c2-6ff5-47b2-9e3c-cacae8de1e 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 2011. http://lib.myilibrary.com?id=324652&entityid=https://shibboleth.plymouth.ac.uk/idp/shibb oleth 39 Flin RH, Mitchell L. Safer surgery: analysing behaviour in the operating theatre. Farnham, England: : Ashgate 2009. http://lib.myilibrary.com?id=226129&entityid=https://shibboleth.plymouth.ac.uk/idp/shibb 6/10

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what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. Advances in Health Sciences Education 2013;18:787 805. doi:10.1007/s10459-012-9400-1 47 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;22:129 35. doi:10.1258/hsmr.2008.008019 48 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;29:30 50. doi:10.1111/scs.12136 49 Incidence of Adverse Events and Negligence in Hospitalized Patients. New England Journal of Medicine 1991;325:210 210. doi:10.1056/nejm199107183250316 50 Perrow C. Normal accidents: living with high-risk technologies. Basic Books 1984. 51 Carthey J. Institutional resilience in healthcare systems. Quality in Health Care 2001;10 :29 32. doi:10.1136/qhc.10.1.29 52 An introduction to the NHS change model - NHS IQ. http://www.nhsiq.nhs.uk/8535.aspx 53 The Nut Island Effect. http://www.asme.org.uk/images/pdfs/2013/the_nut_island_effect.pdf 8/10

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;24:369 76. doi:10.1136/bmjqs-2014-003691 55 TIM SCOTT. Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care 2003;15 :111 8.http://intqhc.oxfordjournals.org.plymouth.idm.oclc.org/content/15/2/111 56 Cochrane Review Abstracts: the effectiveness of strategies to change culture in healthcare. Canadian Journal of Dental Hygiene Published Online First: 2011.http://search.ebscohost.com.plymouth.idm.oclc.org/login.aspx?direct=true&Aut htype=ip,url,shib&db=rzh&an=104517110&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:10.1186/1748-5908-6-33 58 Hogan SJ, Coote LV. Organizational culture, innovation, and performance: A test of Schein s model. Journal of Business Research 2014;67:1609 21. doi:10.1016/j.jbusres.2013.09.007 59 Kannampallil TG, Schauer GF, Cohen T, et al. Considering complexity in healthcare systems. Journal of Biomedical Informatics 2011;44:943 7. doi:10.1016/j.jbi.2011.06.006 60 9/10

Shojania KG, Dixon-Woods M. Bad apples : time to redefine as a type of systems problem? BMJ Quality & Safety 2013;22:528 31. doi:10.1136/bmjqs-2013-002138 61 Reason J. Human error: models and management. BMJ 2000;320:768 70. doi:10.1136/bmj.320.7237.768 62 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;23:106 15. doi:10.1136/bmjqs-2013-001947 63 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;17:947 55. doi:10.1111/j.1365-2834.2009.01022.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;3:179 89. doi:10.1007/s40037-014-0126-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:ii16 21. doi:10.1136/qshc.2003.009514 10/10