Objectives To document the burden of in-hospital falls and fractures, and to identify factors that may increase the risk of these events. Design A retrospective cohort analysis Setting The study was ...

Background Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can ...

Background With the introduction of Computerised Physician Order Entry (CPOE) in routine hospital care, a great deal of effort has been put into refining Clinical Decision Support Systems (CDSS) to ...

LEARNING FROM CLINICAL MICROSYSTEMS. We have worked with several microsystems seeking to improve their care for patients. Some of them seemed to have a clear sense of their identity as a system and, ...

In the past 15 years, SEIPS (Systems Engineering Initiative for Patient Safety)1–3 and related conceptual models4 5 were developed to study and improve healthcare. These theoretical models depict how ...

Footnotes. Contributors All authors made substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data; all authors participated in ...

Background Nurses, midwives and paramedics comprise over half of the clinical workforce in the UK National Health Service and have some of the highest prevalence of psychological ill health. This ...

Quality indicators are ubiquitous in healthcare and serve a variety of purposes for many different stakeholders. Few would question the value of monitoring the quality of care, but the increasing ...

Background Surgical errors in ophthalmology can have devastating consequences. We developed an artificial intelligence (AI)-based surgical safety system to prevent errors in patient identification, ...

Innovation is often regarded as uniformly positive. This paper shows that the role of innovation in quality improvement is more complicated. The authors identify three known paradoxes of innovation in ...

In Plato's Theaetetus , knowledge is defined as the intersection of truth and belief, where knowledge cannot be claimed if something is true but not believed or believed but not true. Using an example ...

Background Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient ...