Compromising patient safety: Lessons learnt from some critical incidents

Lessons learnt from errors in radiotherapy centers

Background: The purpose of this work is to discover and analyze errors and incidents in some radiotherapy centers, and to introduce methods that could reduce their occurrences, especially those which had happened due to the use of improper and inadequate equipment. This work is a first step toward clarifying the role of education in a risk-conscious culture, and changing the attitude of radioth...

Safety of doctors at work: lessons learnt from personal experience.

Drowning and near-drowning--some lessons learnt.

Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pul...

Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP.

OBJECTIVE To describe the development process and characteristics of a patient safety incidents reporting system to be implemented in the Spanish National Health System, based on the context and the needs of the different stakeholders. DESIGN Literature review and analysis of most relevant reporting systems, identification of more than 100 stakeholder's (patients, professionals, regional gove...

Learning from critical incidents

Ian Clarke is a consultant in general adult psychiatry in the west of Glasgow (Arndale Resource Centre, 80–90 Kinfauns Drive, Drumchapel, Glasgow, G15 7TS, UK. Email: [email protected]). He is clinical lead for the Greater Glasgow and Clyde Patient Safety Group. He obtained a Masters in Business Administration in 2004 and is lead clinician for the west of Glasgow. Critical incidents in...