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NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.

Zoe BrummellCecilia Vindrola-PadrosDorit BraunS Ramani Moonesinghe
Published in: BMJ open (2021)
The wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.
Keyphrases
  • patient safety
  • quality improvement
  • adverse drug
  • study protocol
  • high resolution
  • emergency department
  • genome wide
  • gene expression
  • drug induced