Resources for Chapter 20

Risk Management in Healthcare

What the chapter is about

This chapter describes the key role that risk management plays in health care. It starts by describing how the aviation industry influenced health care. The chapter goes on to describe the need for a no-blame culture, approaches to risk management and the use of critical incident reporting systems.

Listen to an AI-generated discussion about the contents of the chapter

The case studies from this chapter are from:

  • Australia
  • Canada
  • China
  • England
  • United States

References with links to full text where available

Canadian Medical Association journal (2001) Error and blame: the Winnipeg inquest. CMAJ: Canadian Medical Association journal/journal de l’Association medicale canadienne, 165(11), 1461–1463.

Dekker (2011) Patient Safety: A Human Factors Approach, CRC Press, ISBN-13: 978-1-4398-5226-2
https://students.aiu.edu/submissions/profiles/resources/onlineBook/h6F4r4_Patient_Safety.pdf

Haugen AS, Sevdalis N, and Søfteland E (2019} Impact of the World Health Organisation Surgical Safety Checklist on Patient Safety. Anesthesiology; 131:420–425 https://doi.org/10.1097/ALN.0000000000002674

Jackson, D., Peters, K., Andrew, S., Edenborough, M., Halcomb, E., Luck, L., … & Wilkes, L. (2010). Understanding whistleblowing: qualitative insights from nurse whistleblowers. Journal of advanced nursing, 66(10), 2194-2201.
https://www.academia.edu/download/43213229/Understanding_whistleblowing_qualitative20160229-9303-1wil3ld.pdf

John Hopkins, (2011) Safety Checklist Use Yields 10 Percent Drop in Hospital Deaths, Press Release, January 31, 2011
https://www.hopkinsmedicine.org/news/media/releases/safety_checklist_use_yields_10_percent_drop_in_hospital_deaths

Kennedy, I (2001) Learning from Bristol: The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary: 1984–1995, Presented to Parliament by the Secretary of State for Health by Command of Her Majesty July 2001, CM 5207(I)
http://www.bristol-inquiry.org.uk/final_report/the_report.pdf

The Health Foundation (2005) Shipman inquiry, Policy Navigator
https://navigator.health.org.uk/theme/shipman-inquiry

The Nursing and Midwifery Council (2015) Professional standards of practice and behaviour for nurses, midwives and nursing associates
https://www.nmc.org.uk/standards/code/read-the-code-onlineJackson

Parker, J., & Davies, B. (2020). No Blame No Gain? From a No Blame Culture to a Responsibility Culture in Medicine. Journal of applied philosophy, 37(4), 646–660.
https://doi.org/10.1111/japp.12433

Provincial Court of Manitoba; (1999) Inquest, Manitoba Pediatric Cardiac Surgery. Winnipeg, Manitoba:. ISBN 0771115164.
http://www.pediatriccardiacinquest.mb.ca/pdf/index.html

Schelkun, S.R.(2014)  Lessons from aviation safety: “plan your operation – and operate your plan!”. Patient Saf Surg 8, 38       
https://doi.org/10.1186/s13037-014-0038-1

Shi, C., Zhang, Y., Li, C., Li, P., & Zhu, H. (2020). Using the Delphi method to identify risk factors contributing to adverse events in residential aged care facilities. Risk Management and Healthcare Policy, 523-537.
https://www.tandfonline.com/doi/pdf/10.2147/RMHP.S243929

Weerakkody RA, Cheshire NJ, Riga C, Lear R, Hamady MS, Moorthy K, Darzi AW, Vincent C, Bicknell CD: (2013) Surgical technology and operating-room safety failures: A systematic review of quantitative studies. BMJ Qual Saf 2013; 22:710–8

Williams N (2018) Gross negligence manslaughter in healthcare: the report of a rapid policy review, June 2018
https://assets.publishing.service.gov.uk/media/5b2a3634ed915d2cc8317662/Williams_Report.pdf

Wolvaardt, E. (2019). Blame does not keep patients safe. Community eye health, 32(106), 36.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802475/

World Health Organisation (2009) WHO Guidelines for safe surgery: safe surgery saves lives, ISBN: 9789241598552, WHO, Geneva 
https://www.who.int/publications/i/item/9789241598552

WHO (2018) Minimal Information Model User Guide, WHO/HIS/SDS/2016.22, WHO Geneva
https://iris.who.int/bitstream/handle/10665/255642/WHO-HIS-SDS-2016.22-eng.pdf?sequence=1 World Health Organization. (2021). Global patient safety action plan 2021-2030: towards eliminating avoidable harm in health care. World Health Organization.

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