Patient safety and the problem of many hands

BMJ Quality and Safety

Volumn 25, Issue 7, 2016, Pages 485-488

  Dixon Woods, Mary ^a   Pronovost, Peter J ^b,c  

^a UNIVERSITY OF LEICESTER   (United Kingdom)

^b JOHNS HOPKINS UNIVERSITY   (United States)

^c JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL PRACTICE; COORDINATION; GROUP DYNAMICS; HEALTH CARE; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HUMAN; NOTE; PATIENT ADVOCACY; PATIENT SAFETY; PROBLEM SOLVING; RISK ASSESSMENT; TOTAL QUALITY MANAGEMENT; CLINICAL COMPETENCE; HEALTH CARE DELIVERY; HEALTH CARE QUALITY; ORGANIZATION AND MANAGEMENT; SAFETY; STANDARDS; SYSTEM ANALYSIS;

CLINICAL COMPETENCE; DELIVERY OF HEALTH CARE; HUMANS; PATIENT SAFETY; QUALITY IMPROVEMENT; QUALITY INDICATORS, HEALTH CARE; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; SYSTEMS INTEGRATION;

EID: 84979246956     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2016-005232     Document Type: Note

References (26)

1. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010;363:2124-34
2. Provenzano A, Rohan S, Trevejo E, et al. Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers. BMJ Qual Saf 2015;24:31-7
3. Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 2012;21:737-45
4. Lamont T, Waring J. Safety lessons: shifting paradigms and new directions for patient safety research. J Health Serv Res Policy 2015;20(1 Suppl):1-8
5. Thompson DF. Moral responsibility of public officials: the problem of many hands. Am Polit Sci Rev 1980;74:905-16
6. Aveling EL, Parker M, Dixon-Woods M. What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociol Health Illn 2016;38:216-32
7. Bovens M. The quest for responsibility: accountability and citizenship in complex organizations. Cambridge: Cambridge University Press, 1998
8. Thompson DF. Responsibility for failures of government the problem of many hands. Amer Rev Public Adm 2014;44:259-73
9. Van de Poel I, Fahlquist JN, Doorn N, et al. The problem of many hands: climate change as an example. Sci Eng Ethics 2012;18:49-67
10. Van de Poel I, Royakkers L. Ethics, technology, and engineering: an introduction. John Wiley & Sons, 2011
11. Klijn EH, Koppenjan JFM. Accountable networks. In: Bovens M, Goodin RE, Schillemans T, eds. Oxford handbook of public accountability. Oxford: Oxford University Press, 2014:242-57
12. Bovens M, Schillemans T, T'Hart P. Does public accountability work? An assessment tool. Public Adm 2008;86:225-42
13. Macrae C. Close calls: managing risk and resilience in airline flight safety. Basingstoke: Palgrave Macmillan, 2014
14. Macrae C. Learning from patient safety incidents: creating participative risk regulation in healthcare. Health Risk Soc 2008;10:53-67
15. Pronovost PJ, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood) 2009;28:w479-89
16. Macrae C. The problem with incident reporting. BMJ Qual Saf 2015; doi:10.1136/bmjqs-2015-004732
17. Austin JM, Jha AK, Romano PS, et al. National hospital ratings systems share few common scores and may generate confusion instead of clarity. Health Aff (Millwood) 2015;34:423-30
18. Shojania KG. Deaths due to medical error: jumbo jets or just small propeller planes?. BMJ Qual Saf 2012;21:709-12
19. Toft B. External inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. London: Department of Health: 2001
20. Wachter RM. The digital doctor: hope, hype, and harm at the dawn of medicine's computer age. New York:McGraw-Hill, 2015
21. Dixon-Woods M, Martin G, Tarrant C, et al. Safer Clinical Systems: evaluation findings. Learning from the independent evaluation of the second phase of the Safer Clinical Systems programme. London: The Health Foundation, 2015
22. Sehgal NL, Wachter RM. Color-coded wristbands: Promoting safety or confusion? J Hosp Med 2007;2:445
23. Macrae C, Vincent C. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med 2014;107:439-43
24. Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89:167-205
25. Rhodes R. How to manage your policy network. Workshop paper for the Commonwealth Secretariat, London 7th to 8th February; 2013
26. Martin G, Armstrong N, Aveling EL, et al. Professionalism redundant, reshaped or reinvigorated? Realizing the "third logic" in contemporary health care. J Health Soc Behav 2015;56:378-97.