Safety in healthcare is a constantly moving target. As standards improve and concern for safety grows, we come to regard an increasing number of events as patient safety issues. In this respect, ...

The role and value of theory in improvement work in healthcare has been seriously underrecognised. We join others in proposing that more informed use of theory can strengthen improvement programmes ...

Objective To contextualise the degree of harm that comes from unsafe medical care compared with individual health conditions using the global burden of disease (GBD), a metric to determine how much ...

In a companion paper, we proposed that cognitive debiasing is a skill essential in developing sound clinical reasoning to mitigate the incidence of diagnostic failure. We reviewed the origins of ...

This example provides a summary of a real case that occurred in a hospital and the failure to learn from the incident in spite of a root cause analysis. In a large acute hospital, a patient underwent ...

Ten years ago, the Institute of Medicine reported alarming data on the scope and impact of medical errors in the US and called for national efforts to address this problem. While efforts to improve ...

Department of Learning, Informatics, Management and Ethics (LIME), Medical Management Centre (MMC), Karolinska Institutet, Stockholm, Sweden Correspondence to Susanne Ullström, Department of Learning, ...

While there is an increasing emphasis on patient empowerment and shared decision making, evidence suggests that many patients do not wish to be involved in decisions about their own care. Previous ...

1 Research Pharmacist, Department of Practice and Policy, The School of Pharmacy, University of London, London WC1N 1AX, UK 2 Senior Lecturer and Honorary Consultant Physician, Clinical Pharmacology, ...

Background The ability to capture the complexities of healthcare practices and the quick turnaround of findings make rapid ethnographies appealing to the healthcare sector, where changing ...

Background Patient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement. Objective To systematically evaluate the use of patient complaint ...

Background Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an ...