Abstract
Reducing medical errors has become an international concern. Population-based studies from a number of nations around the world have consistently demonstrated unacceptably high rates of medical injury and preventable deaths. The introduction of effective reporting systems is a cornerstone of safe practice within hospitals and other healthcare organisations. Reporting can help to identify hazards and risks. However, reporting in itself does not improve safety. It is the response to reports that leads to change. Clinical teams must feel empowered to change the way in which they deliver their services, promoting effective clinical risk management. Process analysis, implementation of evidence-based practices, and a clear accountability system are effective tools not only for decreasing error rates, but also for improving effectiveness. Clinical Governance represents the context in which effective clinical risk management should be promoted and continuously improved. It should not be regarded as a separate activity, but should form part of the everyday practice of all healthcare professionals. It requires good multidisciplinary working and a willingness to reflect on and learn from errors to achieve a patient-centred and safer system.
References
1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: building a safer health system. Washington, DC: National Academy Press, 1999.Search in Google Scholar
2. Altman DE, Clancy C, Blendon RJ. Improving patient safety – five years after the IOM report. N Engl J Med 2004; 351:2041–3.10.1056/NEJMp048243Search in Google Scholar
3. Bion JF, Heffner JE. Challenges in the care of the acutely ill. Lancet 2004; 363:970–7.10.1016/S0140-6736(04)15793-0Search in Google Scholar
4. Mohammed MA, Cheng KK, Rouse A, Marshall T. Bristol, Shipman, and clinical governance: Shewhart's forgotten lessons. Lancet 2001; 357:463–7.10.1016/S0140-6736(00)04019-8Search in Google Scholar
5. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. Br Med J 1998; 317:61–5.10.1136/bmj.317.7150.61Search in Google Scholar PubMed PubMed Central
6. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of practising physicians and the public on medical errors. N Engl J Med 2002; 347:1933–40.10.1056/NEJMsa022151Search in Google Scholar PubMed
7. McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine Report. J Am Med Assoc 2000; 284:93–4.10.1001/jama.284.1.93Search in Google Scholar PubMed
8. Leape LL. Institute of Medicine medical errors figures are not exaggerated. J Am Med Assoc 2000; 284:95–7.10.1001/jama.284.1.95Search in Google Scholar PubMed
9. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety – United States, 1990–1999. MMWR Morb Mortal Wkly Rep 2000;49:149–53.Search in Google Scholar
10. Wenzel R, Edmond M. The impact of hospital-acquired bloodstream infections. Emerg Infect Dis 2001; 7:174–7.10.3201/eid0702.010203Search in Google Scholar PubMed PubMed Central
11. World Alliance for Patient Safety. WHO draft guidelines for adverse events reporting and learning systems. www.who.int/patientsafety.Search in Google Scholar
12. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005; 353:1405–9.10.1056/NEJMsb051157Search in Google Scholar PubMed
13. Leape LL, Berwick DM. Five years after To Err is Human. What have we learned? J Am Med Assoc 2005; 293:2384–90.Search in Google Scholar
14. Reason J. Human error. Cambridge: Cambridge University Press, 1990.Search in Google Scholar
15. Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. Br Med J 2004; 329:679–81.10.1136/bmj.329.7467.679Search in Google Scholar PubMed PubMed Central
16. Walshe K. Understanding and learning from organisational failure. Qual Saf Health Care 2003; 12:81–2.10.1136/qhc.12.2.81Search in Google Scholar PubMed PubMed Central
17. Donaldson LJ, Muir Gray JA. Clinical governance: a quality duty for health organisations. Qual Health Care 1998; 7:S37–44.Search in Google Scholar
18. Adams K, Corrigan JM, editors. Priority areas for national action. Washington, DC: National Academy Press, 2003.Search in Google Scholar
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