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Quality and Safety in Health Care 2006;15:388-389; doi:10.1136/qshc.2006.020800
Copyright © 2006 by the BMJ Publishing Group Ltd.
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COMMENTARY

From root causes to safer systems

From root causes to safer systems: international comparisons of nationally sponsored healthcare staff training programmes

L M Wallace

Correspondence to:
Louise M Wallace
Health Services Research Centre, Coventry University, Coventry, UK; l.wallace@coventry.ac.uk

International comparisons of nationally sponsored healthcare staff training programmes

The first 150 words of the full text of this article appear below.

In the UK, the National Health Service (NHS) treats over one million people every day, but international estimates of serious and largely preventable error are around the 10% mark, at least for general hospital care.1,2 The Chief Medical Officers’ report, "An Organisation with a Memory",3 found that there was a lack of systems for reporting and analysing incidents, and a culture of blame that suppressed learning that is not conducive to developing and implementing safety solutions. The Department of Health’s response was to publish "Building a safer NHS for patients",4 which set the policy context for a new body, the National Safety Agency (NPSA). A central objective of the NPSA was to develop a mandatory risk reporting system, which would enable the agency to analyse and integrate these and other sources of safety information to learn lessons and develop and disseminate solutions. An audit . . . [Full text of this article]


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Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme
Jeffrey Braithwaite, Mary T Westbrook, Nadine A Mallock, Joanne F Travaglia, and Rick A Iedema
Qual. Saf. Health Care 2006 15: 393-399. [Abstract] [Full Text] [PDF]





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Copyright © 2006 by the BMJ Publishing Group Ltd.