AHRQ Patient Safety Network ► Learning Not Blaming.

AHRQ Patient Safety Network







Learning Not Blaming.

Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.

The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussionsabout what went wrong, learning from error, and a culture of safety.

Information 
Free full text (PDF) 

Related Resources

STUDY

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

Patterson ME, Bogart MS, Starr KR. J Hosp Med. 2015;10:152-159.

COMMENTARY

Equipped: overcoming barriers to change to improve quality of care (theories of change).

Lachman P, Runnacles J, Dudley J; RCPCH Clinical Standards Committee. Arch Dis Child Educ Pract Ed. 2015;100:13-18.

COMMENTARY

Organisational reporting and learning systems: innovating inside and outside of the box.

Sujan M, Furniss D. Clin Risk. 2015;21:7-12.

STUDY

Junior doctors' views on reporting concerns about patient safety: a qualitative study.

Hooper P, Kocman D, Carr S, Tarrant C. Postgrad Med J. 2015;91:251-256.

View all related resources...