This report for The Health Foundation is excellent. I like the way it is based on research and whilst it doesn't cover any specifically new ground, it does provide insight for anyone wishing to improve the safety of patients in hospital.
"While the knowledge that poor systems can cause harm is not new, this report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients.
The results of this study, covering seven NHS organisations, identify the variation in the reliability of five key healthcare systems and processes:
- availability of information when making clinical decisions
- availability of equipment in operating theatres
- availability of equipment for inserting intravenous lines.
The research, led by Professor Bryony Dean-Franklin, was conducted by The Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College, and Warwick Clinical Systems Improvement (CSI), University of Warwick."