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An organisation with a memory: report of an Expert Group on Learning from Adverse Events in the National Health Service chaired by the Chief Medical Officer - Tapa blanda
Sinopsis
This report sets out to review the nature and extent of serious failures in NHS healthcare. Furthermore it examines the extent to which the NHS has the capacity to learn from such failures when they occur and to recommend measures that could help to ensure that the liklihood of repeated failures is minimized.
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Reseña del editor
This report sets out to review the nature and extent of serious failures in NHS healthcare. Furthermore it examines the extent to which the NHS has the capacity to learn from such failures when they occur and to recommend measures that could help to ensure that the liklihood of repeated failures is minimized.
Reseña del editor
This report sets out to review the nature and extent of serious failures in NHS healthcare. Furthermore it examines the extent to which the NHS has the capacity to learn from such failures when they occur and to recommend measures that could help to ensure that the liklihood of repeated failures is minimized. In its findings the committee draws on the evidence and experience from a range of sectors including industry, aviation, and academic research. The report attempts to put the problems in context and then goes on to identify the scale and nature of the problems using case studies to show the impact of adverse events on individuals. Understanding the causes of the failure and the factors that influence the ability of the organization to learn from failure is addressed. The strengths and weaknesses of the NHS mechanisms for learning from adverse events are also considered.
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