Analysis of Health Care Error Reports

Health Care Errors and Patient Safety

Volumn , Issue , 2009, Pages 224-237

  Cook, Adrian ^a   Scobie, Sarah ^a  

^a NATIONAL PATIENT SAFETY AGENCY   (United Kingdom)

Author keywords

Analysis of health care error reports; Analysis of incident reports in health care; Billings model and patient safety systems; Free text data mining; National Patient Safety Agency (NPSA); Role of analysis in learning from patient safety incidents; Secondary analysis analysing incident descriptions; Simple random sampling of patient safety incidents

Indexed keywords

EID: 79956337677     PISSN: None     EISSN: None     Source Type: Book    
DOI: 10.1002/9781444308150.ch16     Document Type: Chapter

References (26)

1. Barach P, Small S. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. British Medical Journal 2000; 320: 759-63.
2. Department of Health. Building a Safer NHS for Patients. Department of Health, London. Available at www.dh.gov.uk/PublicationsAndStatistics/Publications/Publications PolicyAndGuidance/PublicationsPAmpGBrowsableDocument/fs/en?CONTENT_ID=4097460&chk=gngr/O.
3. Scobie S, Thomson R. Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety. National Patient Safety Agency, London, 2005. Available at http://www.npsa.nhs.uk/site/media/documents/1280_PSO_Report.pdf.
4. National Patient Safety Agency. Seven Steps to Patient Safety. NPSA, London. Available at www.npsa.nhs.uk/health/resources/7steps.
5. National Patient Safety Agency, National Reporting and Learning System dataset: www.npsa.nhs.uk.
6. National Patient Safety Agency. Quarterly National Reporting and Learning System Data Summary, Winter 2006/7. NPSA, London, 2007.
7. World Health Organisation. International Patient Safety Event Classification. WHO, Geneva, 2006.
8. National Patient Safety Agency. Comparative Trust Feedback Reports. NPSA, London, 2006.
9. National Patient Safety Agency. Evaluation Report. NPSA, London.
10. World Alliance for Patient Safety. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. World Health Organisation, Geneva, 2005.
11. Healthcare Commission: www.healthcarecommission.org.uk.
12. Office for National Statistics: www.national-statistics.gov.uk.
13. Medicines and Healthcare products Regulatory Agency: www.mhra.gov.uk.
14. Action against Medical Accidents: www.avma.org.uk.
15. NHS Litigation Authority: www.nhsla.com.
16. Billings CE. The NASA aviation safety reporting system: lessons learned from voluntary incident reporting. In: Enhancing Patient Safety and Reducing Errors in Health Care. Proceedings of the National Patient Safety Foundation Conference. Chicago, 1998: 97-100.
17. National Patient Safety Agency. RLS Quarterly Data Summary, Winter 2006/7. NPSA, London, 2007.
18. National Statistics. Deaths involving MRSA: England and Wales 2001-2005. Health Statistics Quarterly 2007; 33: 76-81. Available at http://www.statistics.gov.uk/downloads/theme_health/HSQ33.pdf.
19. Vincent C, Davy C, Esmail A et al. Learning from Litigation: An Analysis of Claims for Clinical Negligence. University of Manchester, Manchester, 2004. Available at http://www.mbs.ac.uk/research/groups/public-policy-management/documents/lfl-reportvol2-final-revised.pdf.
20. National Patient Safety Agency. Unpublished analysis of clinical negligence claims notified to trusts in 2005 and managed by the NHS Litigation Authority. Available at http://www.npsa.nhs.uk.
21. National Patient Safety Agency. Skin Treatment Fire Risk. Patient Safety Bulletin. NPSA, London, 2007. Available at http://www.npsa.nhs.uk/site/media/documents/2317_PSBulletinJan07.pdf.
22. Manly BFJ. Multivariate Statistical Methods. Chapman and Hall, London, 1991.
23. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. Journal of the American Medical Association 2001; 286: 415-20.
24. Healey F, Scobie S. Slips, Trips and Falls in Hospital. National Patient Safety Agency, London, 2007.
25. National Patient Safety Agency: http://www.npsa.nhs.uk/health/alerts.
26. Carruthers I, Phillips P. Safety First: A Report for Patients, Clinicians and Healthcare Managers. Department of Health, London, 2006.