Biomedical subjects
Publications and source records attributed to Frank Milligan.
Adverse events are a significant cause of unnecessary harm in health care and can lead to both physical and psychological injury and, in some cases, death. This paper, the first in a series of four, outlines the nature and extent of the problem. The overall aim of the series is to enhance knowledge levels among nurses in an attempt to reduce the number of adverse events.
This paper, the second in a series of four on adverse health events, outlines the process for reporting, investigating and learning from clinical incidents. It outlines the nursing contribution and nurses' responsibility with regards to effective clinical risk management in order to achieve a major cornerstone of clinical governance--making the NHS safer for patients.
If the NHS is to achieve its goal of developing a safety culture, active learning from adverse events and near misses is crucial. This paper, the third in the series, will discuss how learning from adverse events is informing practice and promoting the development of a safety culture. It also discusses a number of case studies where learning has occurred from adverse events.
This, the final paper in this series analysing the significance of adverse health-care events and near-miss reporting, explores the requirement of a shift towards a 'blame-free' culture and the potential contribution such a change could bring to health care in terms of reducing risk for patients. Barriers to achieving a blame-free, or 'blame-fair', culture are also examined.
Patient safety is currently an international priority in health care, as it is widely accepted that the quality of healthcare provision, in terms of reducing errors and other forms of unnecessary patient harm, needs to be improved significantly. This article describes the work and position of the National Patient Safety Agency (NPSA) in NHS-funded care. It outlines the contribution made by two nurses who, as clinical specialty advisers (CSAs) in the organisation, are charged with helping to ensure that nursing issues are considered as an integral part of developing solutions to patient safety issues.
This article is the last in this series based on the Seven Steps to Patient Safety. Each article analyses one of the seven steps and offers a resource for healthcare staff to enhance knowledge, skills and attitudes relating to patient safety. This article identifies solutions and actions that healthcare staff can take to improve patient safety.