Health Committee - Sixth Report
Patient Safety
Here you can browse the report together with the Proceedings of the Committee. The published report was ordered by the House of Commons to be printed 18 June 2009.
Contents
Terms of Reference
Summary
1 Introduction
2 Patient safety policy since 2000
3 Measurement and evaluation
How much harm is done to patients?
What does harm to patients cost the NHS?
Conclusion
4 Harmed patients and their families or carers
The role of the coroner
Dealing with complaints
Compensation and redress
Conclusion
5 An open, reporting and learning NHS
The extent of under-reporting
Reasons for under-reporting
Lack of focus in the National Reporting and
Learning System
Inherent limitations of reporting data
Conclusion
6 Patient safety at the front line
Empowerment and improvement
Teamwork and other non-technical skills
Staffing levels
Shortages of staff
European Working Time Directive
Conclusion
7 Technology and patient safety
Automated decision-support
Automatic Identification and Data Capture
Electronic Patient Record
Technical solutions to preventing catastrophic
disasters
Conclusion
8 Education and training curricula
Clinical pharmacology and therapeutics
Diagnosis in general practice
Root-cause analysis
Patient safety in education and training
curricula
Conclusion
9 Commissioning, performance management and
regulation
Failings in commissioning
Commissioning for Quality and Innovation
Never Events
Performance management
Regulation
Annual Health Check
Care Quality Commission
Coordination and cooperation
The role of Monitor
The role of the NHS Litigation Authority
General concerns
Conclusion
10 The role of managers and Boards
Means of improving Boards' approach to
safety
Whistleblowing
Conclusion
11 The role of the DH and Government
Conclusions and recommendations
Glossary
Annex 1: Terms of reference of the inquiry
Annex 2: International case note review studies
Formal Minutes
Witnesses
List of written evidence
List of further written evidence
List of unprinted evidence
List of Reports from the Committee during
the current Parliament
Oral and Written Evidence - HC 151-II
30 October 2008
20 November 2008
15 January 2009
22 January 2009
5 February 2009
5 March 2009
19 March 2009
3 June 2009
Written Evidence
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