Burke et al. carried out a systematic review. All studies that explored an intervention to improve failure to rescue in the adult population were considered. They found that complications occur consistently within healthcare organisations and organisations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context.
The authors propose “The 3 Rs of Failure to Rescue” of recognise, relay and react, and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future effo
Local reporting on complaints is inconsistent and inaccessible.
Staff are not empowered to communicate with the public on complaints.
Reporting focuses on counting complaints, not demonstrating learning.
This thematic review presents a detailed analysis of claims made after an individual has attempted to take their life.Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery.
The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports.
Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient exper
The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.
Medication errors (MEs) are common and persistent problems that may pose significant risk to critically ill children admitted to paediatric and neonatal intensive care units.
Prescribing and medication administration errors were the common types of MEs and dosing errors were the most frequent ME subtype in both paediatric and neonatal intensive care unit settings.
Anti-infective medications were the commonly reported drug class associated with MEs/preventable adverse drug events across both intensive care unit types.
Further research is needed to examine me
About the authors
Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Ha
The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of healthcare.
The results of this study show that poor organisational culture and leadership negatively influences and hinders doctors who make mistakes. Leaders who promote and create environments for open and constructive dialogue following adverse events enable the concept of fallibility and imperfection to be assimilated into new ways of learning. Guilt and fear are the most consistently reported psychological symptoms along with a perception of loss of professional respect and standing. Doctors often carry unresolved trauma for several years causing them to constantly relive an event. Unchecked, this c