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Violations and migrations in health care: a framework for understanding and management

Violations and migrations in health care: a framework for understanding and management

http://www.wikidata.org/entity/Q36672049

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Understanding safety in healthcare: the system evolution, erosion and enhancement model Barriers and bridges to infection prevention and control: results of a qualitative case study of a Netherlands' surgical unit A three-dimensional model of error and safety in surgical health care microsystems. Rationale, development and initial testing Silence that can be dangerous: a vignette study to assess healthcare professionals' likelihood of speaking up about safety concerns Self-reported violations during medication administration in two paediatric hospitals The social process of escalation: a promising focus for crisis management research The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands.The role of the anesthesiologist in perioperative patient safety.Tools for primary care patient safety: a narrative review The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events.People or systems? To blame is human. The fix is to engineer.Missed diagnostic opportunities and English general practice: a study to determine their incidence, confounding and contributing factors and potential impact on patients through retrospective review of electronic medical records How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review.Know your client and know your team: a complexity inspired approach to understanding safe transitions in care.Macroergonomics in Healthcare Quality and Patient Safety.Nursing care and patient safety: visualizing medication organization, storage and distribution with photographic research methods.Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study.A qualitative study on the implementation of quality systems in Australian hospitals.Medication adherence: staying within the boundaries of safety.Gaze entropy reflects surgical task load.Does Psychological Safety Impact the Clinical Learning Environment for Resident Physicians? Results From the VA's Learners' Perceptions Survey.Understanding clinical uncertainty: what is going on when experienced surgeons are not sure what to do?Recognising and responding to 'cutting corners' when providing nursing care: a qualitative study."They Have to Adapt to Learn": Surgeons' Perspectives on the Role of Procedural Variation in Surgical Education.Application of Bow-tie methodology to improve patient safety.Outbreak Column 20: are outbreaks man-made disasters that display intertwined errors of human judgement and behaviour?Value of human factors to medication and patient safety in the intensive care unit.Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.Positive Deviance: A New Tool for Infection Prevention and Patient Safety.Redefining the clinical gaze.Surgical swab counting: a qualitative analysis from the perspective of the scrub nurse.Identifying violation-provoking conditions in a healthcare setting.Toward the modelling of safety violations in healthcare systems.Catching and correcting near misses: the collective vigilance and individual accountability trade-off.Implementing an integrated in-situ coaching, observational audit, and story-telling intervention to support safe surgery.Using a STOP/GO protocol in the preoperative area to increase patient safety.Intermediate care to intensive care triage: A quality improvement project to reduce mortality.Systems Thinking and Leadership: How Nephrologists Can Transform Dialysis Safety to Prevent Infections.'Broken hospital windows': debating the theory of spreading disorder and its application to healthcare organizations."Hand-it-on": an innovative simulation on the relation of non-technical skills to healthcare.

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Violations and migrations in health care: a framework for understanding and management

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Quality and Safety in Health Care

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Violations and migrations in health care: a framework for understanding and management

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Amalberti R

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Auroy Y

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Vincent C

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de Saint Maurice G

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P2860

On error management: lessons from aviation

Exploring the causes of adverse events in NHS hospital practice

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I

Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management

Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers.

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

Determinants of intention to commit driving violations.

Anaesthetists' intentions to violate safety guidelines.

The Nature of Adverse Events in Hospitalized Patients

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10.1136/QSHC.2005.015982

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15 Suppl 1

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