{"id":"https://openalex.org/W192462963","doi":null,"title":"A safer place for patients: learning to improve patient safety","display_name":"A safer place for patients: learning to improve patient safety","publication_year":2005,"publication_date":"2005-11-03","ids":{"openalex":"https://openalex.org/W192462963","mag":"192462963"},"language":"en","primary_location":{"id":"pmh:oai:eprints.whiterose.ac.uk:3427","doi":null,"is_oa":true,"landing_page_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","pdf_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","source":{"id":"https://openalex.org/S4306400854","display_name":"White Rose Research Online (University of Leeds, The University of Sheffield, University of York)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I2800616092","host_organization_name":"White Rose University Consortium","host_organization_lineage":["https://openalex.org/I2800616092"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"","raw_type":"Monograph"},"volume":null,"type":"book","is_traditional":true,"indexed_in":[],"open_access":{"is_oa":true,"oa_status":"green","oa_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","any_repository_has_fulltext":true},"authorships":[{"author_position":"first","author":{"id":null,"display_name":"Amanda Terry","orcid":"https://orcid.org/0000-0002-8157-8298","observed_orcids":["https://orcid.org/0000-0002-8157-8298"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Amanda Terry","raw_affiliation_strings":[],"raw_orcid":"https://orcid.org/0000-0002-8157-8298","affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5060026921","display_name":"Caroline Mottram","orcid":null,"observed_orcids":[]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Caroline Mottram","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5000056359","display_name":"Jonathan A. Round","orcid":"https://orcid.org/0009-0003-7833-3155","observed_orcids":["https://orcid.org/0009-0003-7833-3155"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Jonathan A. Round","raw_affiliation_strings":[],"raw_orcid":"https://orcid.org/0009-0003-7833-3155","affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5054017015","display_name":"E. Firman","orcid":null,"observed_orcids":[]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"E. Firman","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5020538597","display_name":"J. Step","orcid":null,"observed_orcids":[]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"J. Step","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"last","author":{"id":"https://openalex.org/A5090544454","display_name":"Joe Bourne","orcid":"https://orcid.org/0009-0005-5246-4442","observed_orcids":["https://orcid.org/0009-0005-5246-4442"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Joe Bourne","raw_affiliation_strings":[],"raw_orcid":"https://orcid.org/0009-0005-5246-4442","affiliations":[]}],"institutions":[],"countries_distinct_count":0,"institutions_distinct_count":0,"corresponding_author_ids":[],"corresponding_institution_ids":[],"apc_list":null,"apc_paid":null,"fwci":22.0363,"has_fulltext":true,"cited_by_count":115,"citation_normalized_percentile":{"value":0.98885794,"is_in_top_1_percent":false,"is_in_top_10_percent":true},"cited_by_percentile_year":{"min":88,"max":99},"biblio":{"volume":null,"issue":null,"first_page":null,"last_page":null},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9955999851226807,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9955999851226807,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T12871","display_name":"Healthcare Quality and Management","score":0.002899999963119626,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T10809","display_name":"Occupational Health and Safety Research","score":0.0003000000142492354,"subfield":{"id":"https://openalex.org/subfields/3311","display_name":"Safety Research"},"field":{"id":"https://openalex.org/fields/33","display_name":"Social Sciences"},"domain":{"id":"https://openalex.org/domains/2","display_name":"Social Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/patient-safety-incidents","display_name":"patient safety incidents","score":0.7480000257492065},{"id":"https://openalex.org/keywords/near-misses","display_name":"near misses","score":0.9610000252723694},{"id":"https://openalex.org/keywords/incident-reporting","display_name":"incident reporting","score":0.6510000228881836},{"id":"https://openalex.org/keywords/learning-from-incidents","display_name":"learning from incidents","score":0.6909999847412109},{"id":"https://openalex.org/keywords/patient-safety-culture","display_name":"patient safety culture","score":0.734000027179718},{"id":"https://openalex.org/keywords/national-patient-safety-agency","display_name":"National Patient Safety Agency","score":0.8389999866485596},{"id":"https://openalex.org/keywords/national-health-service","display_name":"National Health Service","score":0.5040000081062317},{"id":"https://openalex.org/keywords/organizational-culture","display_name":"organizational culture","score":0.5830000042915344},{"id":"https://openalex.org/keywords/risk-management","display_name":"risk management","score":0.5920000076293945},{"id":"https://openalex.org/keywords/patient-harm","display_name":"patient harm","score":0.4129999876022339},{"id":"https://openalex.org/keywords/national-audit-office","display_name":"National Audit Office","score":0.4259999990463257},{"id":"https://openalex.org/keywords/patient-safety-legislation","display_name":"patient safety legislation","score":0.30799999833106995}],"concepts":[{"id":"https://openalex.org/C2776654903","wikidata":"https://www.wikidata.org/wiki/Q2601463","display_name":"SAFER","level":2,"score":0.8672745227813721},{"id":"https://openalex.org/C199521495","wikidata":"https://www.wikidata.org/wiki/Q181487","display_name":"Audit","level":2,"score":0.6926746368408203},{"id":"https://openalex.org/C2777189325","wikidata":"https://www.wikidata.org/wiki/Q61022630","display_name":"Officer","level":2,"score":0.67844557762146},{"id":"https://openalex.org/C2779328685","wikidata":"https://www.wikidata.org/wiki/Q1475557","display_name":"Patient safety","level":3,"score":0.6738872528076172},{"id":"https://openalex.org/C545542383","wikidata":"https://www.wikidata.org/wiki/Q2751242","display_name":"Medical emergency","level":1,"score":0.4903571605682373},{"id":"https://openalex.org/C206713868","wikidata":"https://www.wikidata.org/wiki/Q1674639","display_name":"Near miss","level":2,"score":0.4872216284275055},{"id":"https://openalex.org/C160735492","wikidata":"https://www.wikidata.org/wiki/Q31207","display_name":"Health care","level":2,"score":0.48172882199287415},{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.4411747455596924},{"id":"https://openalex.org/C184356942","wikidata":"https://www.wikidata.org/wiki/Q830382","display_name":"Best practice","level":2,"score":0.43469470739364624},{"id":"https://openalex.org/C39549134","wikidata":"https://www.wikidata.org/wiki/Q133080","display_name":"Public relations","level":1,"score":0.38154539465904236},{"id":"https://openalex.org/C144133560","wikidata":"https://www.wikidata.org/wiki/Q4830453","display_name":"Business","level":0,"score":0.37878555059432983},{"id":"https://openalex.org/C159110408","wikidata":"https://www.wikidata.org/wiki/Q121176","display_name":"Nursing","level":1,"score":0.32650166749954224},{"id":"https://openalex.org/C38652104","wikidata":"https://www.wikidata.org/wiki/Q3510521","display_name":"Computer security","level":1,"score":0.15834447741508484},{"id":"https://openalex.org/C127413603","wikidata":"https://www.wikidata.org/wiki/Q11023","display_name":"Engineering","level":0,"score":0.15376195311546326},{"id":"https://openalex.org/C17744445","wikidata":"https://www.wikidata.org/wiki/Q36442","display_name":"Political science","level":0,"score":0.13984832167625427},{"id":"https://openalex.org/C77595967","wikidata":"https://www.wikidata.org/wiki/Q3151013","display_name":"Forensic engineering","level":1,"score":0.10578358173370361},{"id":"https://openalex.org/C41008148","wikidata":"https://www.wikidata.org/wiki/Q21198","display_name":"Computer science","level":0,"score":0.0},{"id":"https://openalex.org/C199539241","wikidata":"https://www.wikidata.org/wiki/Q7748","display_name":"Law","level":1,"score":0.0},{"id":"https://openalex.org/C121955636","wikidata":"https://www.wikidata.org/wiki/Q4116214","display_name":"Accounting","level":1,"score":0.0}],"mesh":[],"locations_count":2,"locations":[{"id":"pmh:oai:eprints.whiterose.ac.uk:3427","doi":null,"is_oa":true,"landing_page_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","pdf_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","source":{"id":"https://openalex.org/S4306400854","display_name":"White Rose Research Online (University of Leeds, The University of Sheffield, University of York)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I2800616092","host_organization_name":"White Rose University Consortium","host_organization_lineage":["https://openalex.org/I2800616092"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"","raw_type":"Monograph"},{"id":"mag:192462963","doi":null,"is_oa":false,"landing_page_url":"https://www.nao.org.uk/wp-content/uploads/2005/11/0506456.pdf","pdf_url":null,"source":null,"license":null,"license_id":null,"version":null,"is_accepted":false,"is_published":false,"raw_source_name":null,"raw_type":null}],"best_oa_location":{"id":"pmh:oai:eprints.whiterose.ac.uk:3427","doi":null,"is_oa":true,"landing_page_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","pdf_url":"http://eprints.whiterose.ac.uk/3427/1/NAO_2005_a_safer_place.pdf","source":{"id":"https://openalex.org/S4306400854","display_name":"White Rose Research Online (University of Leeds, The University of Sheffield, University of York)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I2800616092","host_organization_name":"White Rose University Consortium","host_organization_lineage":["https://openalex.org/I2800616092"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"","raw_type":"Monograph"},"sustainable_development_goals":[{"display_name":"Good health and well-being","id":"https://metadata.un.org/sdg/3","score":0.9476000070571899}],"study_designs":[],"awards":[],"funders":[],"has_content":{"grobid_xml":true,"pdf":true},"content_urls":{"pdf":"https://content.openalex.org/works/W192462963.pdf","grobid_xml":"https://content.openalex.org/works/W192462963.grobid-xml"},"referenced_works_count":0,"referenced_works":[],"related_works":["https://openalex.org/W2154032858","https://openalex.org/W4231831555","https://openalex.org/W2069240047","https://openalex.org/W2141480620","https://openalex.org/W1853863621","https://openalex.org/W2038973293","https://openalex.org/W2519209937","https://openalex.org/W7097956744","https://openalex.org/W1992547985","https://openalex.org/W2565888781"],"abstract_inverted_index":{"1":[0],"Every":[1],"day":[2],"over":[3],"one":[4,66],"million":[5],"people":[6],"are":[7,110,598,653,777],"treated":[8],"\\nsuccessfully":[9],"by":[10,305,388,579,616,720,733],"National":[11,297,314,704,715,788],"Health":[12,61],"Service":[13],"(NHS)":[14],"acute,":[15,378],"\\nambulance":[16],"and":[17,34,36,55,135,163,167,170,178,226,236,256,271,287,322,338,361,380,411,417,429,434,458,465,481,490,520,530,573,577,664,700,711,717,754],"mental":[18,381],"health":[19,382],"trusts.":[20,786],"However,":[21,142],"healthcare":[22,53,413],"\\nrelies":[23],"on":[24,160,544],"a":[25,78,114,143,202,230,249,257,277,330,373,389,446,478,568,583,671],"range":[26],"of":[27,30,60,89,124,131,145,165,215,229,276,309,332,369,375,398,474,488,534,537,562,575,626,666,695,698,799],"complex":[28],"interactions":[29],"people,":[31],"\\nskills,":[32],"technologies":[33],"drugs,":[35],"sometimes":[37],"things":[38],"do":[39],"\\ngo":[40],"wrong.":[41],"For":[42],"most":[43],"countries,":[44],"patient":[45,91,132,216,261,284,303,356,364,455,586,661],"safety":[46,92,133,217,285,304,357,365,456,608,662],"is":[47,567,589,612],"now":[48],"the":[49,121,155,161,194,208,213,245,274,292,296,307,348,355,418,453,468,471,535,540,546,559,601,617,624,640,684,714,731,751,806,817],"\\nkey":[50],"issue":[51],"in":[52,67,116,120,269,353,384,391,406,424,452,501,558,585,632,657,821],"quality":[54],"risk":[56,308,629],"management.":[57],"\\nThe":[58,787],"Department":[59,246],"(the":[62],"Department)":[63],"estimates":[64],"\\nthat":[65,154,506],"ten":[68],"patients":[69,118,399],"admitted":[70],"to":[71,81,128,138,211,266,301,462,492,511,570,634,660,730,750,762,797],"NHS":[72,156,184,251,349,377,641],"hospitals":[73],"will":[74],"be":[75],"\\nunintentionally":[76],"harmed,":[77],"rate":[79],"similar":[80],"other":[82,407],"developed":[83,477],"\\ncountries.":[84],"Around":[85],"50":[86],"per":[87],"cent":[88],"these":[90,176,776],"\\nincidentsa":[93],"could":[94],"have":[95,151,476,678],"been":[96,105,553],"avoided,":[97],"if":[98],"only":[99],"lessons":[100,238,337,576,597,767],"from":[101,175,329,363,766,769,805],"\\nprevious":[102],"incidents":[103,134,169,177,218,286],"had":[104,509,745],"learned.":[106],"\\n":[107,189,190,240,241,341,342,440,441,605,674,757],"\\n2":[108],"\\nThere":[109],"numerous":[111],"stakeholders":[112],"with":[113,201,445,486,513,526,582],"role":[115],"\\nkeeping":[117],"safe":[119],"NHS,":[122],"many":[123],"whom":[125],"require":[126],"\\ntrusts":[127,515],"report":[129,198,815],"details":[130],"near":[136,288,701],"\\nmisses":[137],"them":[139],"(Figure":[140],"2).":[141,401],"number":[144,214],"previous":[146],"\\nNational":[147,419,427,752],"Audit":[148],"Office":[149],"reports":[150],"highlighted":[152],"concerns":[153],"has":[157,350,552,792],"limited":[158,795],"information":[159,328],"extent":[162],"\\nimpact":[164],"clinical":[166,619],"non-clinical":[168],"trusts":[171,383,475,525,611,652,677,727,743,760,798],"need":[172,569],"\\nto":[173,291],"learn":[174,336],"share":[179],"good":[180,498],"practice":[181],"across":[182],"\\nthe":[183,227,460],"more":[185,514,627],"effectively":[186],"(Appendix":[187,400,409,415,432,438,649],"1).":[188],"\\n3":[191,564],"In":[192,243],"2000,":[193],"Chief":[195],"Medical":[196],"Officer\u2019s":[197],"An":[199,443],"\\norganisation":[200],"memory":[203],"\\n1":[204],"\\n,":[205],"identified":[206],"that":[207,223,596],"key":[209],"\\nbarriers":[210],"reducing":[212,306],"\\nwere":[219],"an":[220,395,449,518],"organisational":[221],"culture":[222,484,609],"inhibited":[224],"reporting":[225,270,281,360,464,483,516,522,528,548,681],"lack":[228],"cohesive":[231],"national":[232,280,547,807],"system":[233,593],"for":[234,252,283,496,550,594,647],"identifying":[235],"\\nsharing":[237,497],"learnt.":[239],"\\n4":[242,622],"response,":[244],"published":[247,811],"Building":[248],"\\nsafer":[250],"patients3":[253],"detailing":[254],"plans":[255],"timetable":[258],"\\nfor":[259],"promoting":[260],"safety.":[262,587],"The":[263,313,607,703],"goal":[264],"was":[265,294,318],"encourage":[267],"\\nimprovements":[268],"learning":[272,362,551],"through":[273,311],"\\ndevelopment":[275],"new":[278],"mandatory":[279],"\\nscheme":[282],"misses.":[289,702],"Central":[290],"plan":[293],"establishing":[295],"Patient":[298,315,420,705,789,818],"Safety":[299,316,421,706,790,819],"\\nAgency":[300,707],"improve":[302,463,493,512],"\\nharm":[310],"error.":[312],"Agency":[317,791],"\\nexpected":[319],"to:":[320],"collect":[321],"analyse":[323],"information;":[324],"assimilate":[325],"\\nother":[326,435],"safety-related":[327],"variety":[331],"existing":[333],"\\nreporting":[334,773,808],"systems;":[335],"produce":[339],"solutions.":[340],"\\n5":[343],"We":[344,402],"therefore":[345],"examined":[346],"whether":[347],"\\nbeen":[351],"successful":[352],"improving":[354],"culture,":[358,523],"\\nencouraging":[359],"\\nincidents.":[366],"Key":[367],"parts":[368,665],"our":[370,502],"approach":[371],"were":[372,728],"census":[374],"\\n267":[376],"ambulance":[379],"\\nAutumn":[385],"2004,":[386],"followed":[387],"re-survey":[390,503],"August":[392,738],"2005":[393],"\\nand":[394,565,623],"omnibus":[396],"survey":[397],"also":[403,590],"\\nreviewed":[404],"practices":[405],"industries":[408],"3)":[410],"\\ninternational":[412],"systems":[414,529,631,682],"4),":[416],"Agency\u2019s":[422],"progress":[423,543],"developing":[425,545],"its":[426,812],"Reporting":[428,753],"Learning":[430,718,755],"System":[431,719],"5)":[433],"related":[436],"activities":[437],"6).":[439],"\\n6":[442],"organisation":[444],"memory1":[447],"\\nwas":[448],"important":[450],"\\nmilestone":[451],"NHS\u2019s":[454],"agenda":[457],"marked":[459],"drive":[461],"learning.":[466],"At":[467,539],"\\nlocal":[469,602],"level":[470],"vast":[472],"majority":[473],"\\npredominantly":[479],"open":[480,519,527],"fair":[482,521],"but":[485,775],"\\npockets":[487],"blame":[489,672],"scope":[491],"their":[494,770],"strategies":[495],"practice.":[499],"Indeed":[500],"we":[504],"found":[505],"local":[507,685,771],"performance":[508],"continued":[510],"having":[517],"\\nmore":[524],"improvements":[531,764],"\\nin":[532],"perceptions":[533],"levels":[536],"under-reporting.":[538],"\\nnational":[541],"level,":[542,686],"\\nsystem":[549,732],"slower":[554],"than":[555],"set":[556],"out":[557,713],"\\nDepartment\u2019s":[560],"strategy":[561],"2001":[563],"there":[566],"\\nimprove":[571],"evaluation":[572],"sharing":[574],"solutions":[578],"\\nall":[580],"organisations":[581,668],"stake":[584],"There":[588],"\\nno":[591],"clear":[592],"monitoring":[595],"learned":[599],"at":[600,740],"level.":[603],"Specifically:":[604],"\\na":[606,690],"within":[610,692,783],"improving,":[613],"driven":[614],"\\nlargely":[615],"Department\u2019s":[618],"governance":[620],"\\ninitiative":[621],"development":[625],"effective":[628,680],"\\nmanagement":[630],"response":[633,659],"incentives":[635],"under":[636],"\\ninitiatives":[637],"such":[638],"as":[639],"Litigation":[642],"Authority\u2019s":[643],"\\nClinical":[644],"Negligence":[645],"Scheme":[646],"Trusts":[648],"7).":[650],"\\nHowever,":[651],"still":[654,669,744,778],"predominantly":[655],"reactive":[656],"\\ntheir":[658],"issues":[663],"\\nsome":[667],"operate":[670],"culture.":[673],"\\nb":[675],"All":[676,726],"established":[679],"\\nat":[683],"although":[687],"under-reporting":[688],"remains":[689],"problem":[691],"some":[693],"groups":[694],"staff,":[696],"types":[697],"\\nincidents":[699],"did":[708],"not":[709,746,779],"develop":[710],"roll":[712],"\\nReporting":[716],"December":[721,735],"2002":[722],"\\nas":[723],"originally":[724],"envisaged.":[725],"linked":[729],"31":[734],"2004.":[736],"By":[737],"2005,":[739],"\\nleast":[741],"35":[742],"submitted":[747],"any":[748],"data":[749],"System.":[756],"\\nc":[758],"Most":[759],"pointed":[761],"specific":[763],"\\nderived":[765],"learnt":[768],"incident":[772],"systems,":[774],"widely":[780],"\\npromulgated,":[781],"either":[782],"or":[784,802],"between":[785],"provided":[793],"\\nonly":[794],"feedback":[796,814],"evidence-based":[800],"\\nsolutions":[801],"actions":[803],"derived":[804],"system.":[809],"It":[810],"first":[813],"\\nfrom":[816],"Observatory":[820],"July":[822],"2005.":[823]},"counts_by_year":[{"year":2025,"cited_by_count":1},{"year":2023,"cited_by_count":1},{"year":2022,"cited_by_count":3},{"year":2021,"cited_by_count":2},{"year":2018,"cited_by_count":2},{"year":2017,"cited_by_count":3},{"year":2016,"cited_by_count":2},{"year":2015,"cited_by_count":5},{"year":2014,"cited_by_count":3},{"year":2013,"cited_by_count":5},{"year":2012,"cited_by_count":13}],"updated_date":"2026-11-03T10:50:19.383937","created_date":"2016-06-24T00:00:00"}