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Over the past three decades, the predominant approach to improving safety in health care has involved studying adverse outcomes to identify system vulnerabilities and correct them. While this approach has been useful, it has limitations. A focus only on unfavourable outcomes can limit innovation and adaptability, not to mention undermine worker morale and engagement.
Numerous studies about the use of trigger tools to identify adverse events (AEs) have been performed in hospitals. However, the research conducted on the use of trigger tools to identify AEs in primary care is limited.
This study developed a set of triggers for identifying adverse events in Primary Care, from health record reviews with high positive predictive value (PPV), making it easier to collect reliable information on care-related incidents in this sector. It also presents interesting data on adverse event prevalence in Primary Care.
That depends on the answer to these questions.
The central role played by governance and leadership in the actions (and inactions) relating to quality of care and patient safety has been repeatedly identified by inquiries and investigations into major organisational failures. They show that governance and leadership - through their influence on priorities, oversight, management and culture – are often part of both problem and solution.
This article addresses the question of to what extent changes in legislation and regulatory standards in aged care and disability create new expectations of these boards and directors.
This article examines what might be learnt from both literatures and considers what findings might – and might not – be hypothesised to be transferable to the governance of disability service providers.
