Clinical Governance: from clinical risk management to continuous quality improvement
-
Maria Laura Chiozza
Abstract
Reducing medical errors has become an international concern. Population-based studies from a number of nations around the world have consistently demonstrated unacceptably high rates of medical injury and preventable deaths. The introduction of effective reporting systems is a cornerstone of safe practice within hospitals and other healthcare organisations. Reporting can help to identify hazards and risks. However, reporting in itself does not improve safety. It is the response to reports that leads to change. Clinical teams must feel empowered to change the way in which they deliver their services, promoting effective clinical risk management. Process analysis, implementation of evidence-based practices, and a clear accountability system are effective tools not only for decreasing error rates, but also for improving effectiveness. Clinical Governance represents the context in which effective clinical risk management should be promoted and continuously improved. It should not be regarded as a separate activity, but should form part of the everyday practice of all healthcare professionals. It requires good multidisciplinary working and a willingness to reflect on and learn from errors to achieve a patient-centred and safer system.
References
1. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: building a safer health system. Washington, DC: National Academy Press, 1999.Suche in Google Scholar
2. Altman DE, Clancy C, Blendon RJ. Improving patient safety – five years after the IOM report. N Engl J Med 2004; 351:2041–3.10.1056/NEJMp048243Suche in Google Scholar
3. Bion JF, Heffner JE. Challenges in the care of the acutely ill. Lancet 2004; 363:970–7.10.1016/S0140-6736(04)15793-0Suche in Google Scholar
4. Mohammed MA, Cheng KK, Rouse A, Marshall T. Bristol, Shipman, and clinical governance: Shewhart's forgotten lessons. Lancet 2001; 357:463–7.10.1016/S0140-6736(00)04019-8Suche in Google Scholar
5. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. Br Med J 1998; 317:61–5.10.1136/bmj.317.7150.61Suche in Google Scholar PubMed PubMed Central
6. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of practising physicians and the public on medical errors. N Engl J Med 2002; 347:1933–40.10.1056/NEJMsa022151Suche in Google Scholar PubMed
7. McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine Report. J Am Med Assoc 2000; 284:93–4.10.1001/jama.284.1.93Suche in Google Scholar PubMed
8. Leape LL. Institute of Medicine medical errors figures are not exaggerated. J Am Med Assoc 2000; 284:95–7.10.1001/jama.284.1.95Suche in Google Scholar PubMed
9. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety – United States, 1990–1999. MMWR Morb Mortal Wkly Rep 2000;49:149–53.Suche in Google Scholar
10. Wenzel R, Edmond M. The impact of hospital-acquired bloodstream infections. Emerg Infect Dis 2001; 7:174–7.10.3201/eid0702.010203Suche in Google Scholar PubMed PubMed Central
11. World Alliance for Patient Safety. WHO draft guidelines for adverse events reporting and learning systems. www.who.int/patientsafety.Suche in Google Scholar
12. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005; 353:1405–9.10.1056/NEJMsb051157Suche in Google Scholar PubMed
13. Leape LL, Berwick DM. Five years after To Err is Human. What have we learned? J Am Med Assoc 2005; 293:2384–90.Suche in Google Scholar
14. Reason J. Human error. Cambridge: Cambridge University Press, 1990.Suche in Google Scholar
15. Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. Br Med J 2004; 329:679–81.10.1136/bmj.329.7467.679Suche in Google Scholar PubMed PubMed Central
16. Walshe K. Understanding and learning from organisational failure. Qual Saf Health Care 2003; 12:81–2.10.1136/qhc.12.2.81Suche in Google Scholar PubMed PubMed Central
17. Donaldson LJ, Muir Gray JA. Clinical governance: a quality duty for health organisations. Qual Health Care 1998; 7:S37–44.Suche in Google Scholar
18. Adams K, Corrigan JM, editors. Priority areas for national action. Washington, DC: National Academy Press, 2003.Suche in Google Scholar
©2006 by Walter de Gruyter Berlin New York
Artikel in diesem Heft
- Foreword
- Evidence-based policy-making
- Clinical Governance – from rhetoric to reality?
- Realising the developmental potential of Clinical Governance
- Re-energising Clinical Governance through Integrated Governance
- Clinical Governance: from clinical risk management to continuous quality improvement
- Involvement of patients in Clinical Governance
- Teaching and Continuing Professional Development: an Italian experience
- New National Healthcare Information System
- Clinical Governance and Laboratory Medicine: is the Electronic Medical Record our best friend or sworn enemy?
- Technology to improve quality and accountability
- Clinical Governance and evidence-based laboratory medicine
- ISO 15189:2003 – Quality management, evaluation and continual improvement
- External Quality Assessment: an effective tool for Clinical Governance in Laboratory Medicine
- Errors in clinical laboratories or errors in laboratory medicine?
- Laboratory request appropriateness in emergency: impact on hospital organization
- Point-of-care-testing and Clinical Governance
- Integration between the Tele-Cardiology Unit and the central laboratory: methodological and clinical evaluation of point-of-care testing cardiac marker in the ambulance
Artikel in diesem Heft
- Foreword
- Evidence-based policy-making
- Clinical Governance – from rhetoric to reality?
- Realising the developmental potential of Clinical Governance
- Re-energising Clinical Governance through Integrated Governance
- Clinical Governance: from clinical risk management to continuous quality improvement
- Involvement of patients in Clinical Governance
- Teaching and Continuing Professional Development: an Italian experience
- New National Healthcare Information System
- Clinical Governance and Laboratory Medicine: is the Electronic Medical Record our best friend or sworn enemy?
- Technology to improve quality and accountability
- Clinical Governance and evidence-based laboratory medicine
- ISO 15189:2003 – Quality management, evaluation and continual improvement
- External Quality Assessment: an effective tool for Clinical Governance in Laboratory Medicine
- Errors in clinical laboratories or errors in laboratory medicine?
- Laboratory request appropriateness in emergency: impact on hospital organization
- Point-of-care-testing and Clinical Governance
- Integration between the Tele-Cardiology Unit and the central laboratory: methodological and clinical evaluation of point-of-care testing cardiac marker in the ambulance
