We may remember but what did we learn? Dealing with errors, crimes and misdemeanours around adverse events in healthcare

Fischbacher-Smith, D. and Fischbacher-Smith, M. (2009) We may remember but what did we learn? Dealing with errors, crimes and misdemeanours around adverse events in healthcare. Financial Accountability and Management, 25(4), pp. 451-474. (doi:10.1111/j.1468-0408.2009.00487.x)

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Publisher's URL: http://dx.doi.org/10.1111/j.1468-0408.2009.00487.x

Abstract

This paper seeks to provide both a retrospective and prospective view on the issues surrounding the generation of adverse events within healthcare. It aims to deal with a range of issues around the individual as a means of making mistakes or violating the rules within the organisation. It sets the issue of patient safety into its historical context before highlighting the shift in thinking that accompanied the publication of an Organisation with a Memory (OWAM) by the Department of Health. The paper considers the challenges that surround the shift away from a person-centric approach to adverse events to one that recognises the importance of latent factors in shaping the conditions in which people can make mistakes and violate. The paper concludes by setting out several propositions for further research and the changes in managerial practice that are needed within healthcare in order to begin to achieve the core aim of OWAM which is to ensure that organisations remember and learn from adverse events.

Item Type:Articles
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Fischbacher-Smith, Professor Moira and Fischbacher-Smith, Professor Denis
Authors: Fischbacher-Smith, D., and Fischbacher-Smith, M.
Subjects:R Medicine > RA Public aspects of medicine
College/School:College of Social Sciences > Adam Smith Business School > Management
Journal Name:Financial Accountability and Management
ISSN:0267-4424
ISSN (Online):1468-0408
Published Online:26 October 2009

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