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dc.contributor.authorOffredy, M.
dc.contributor.authorRhodes, M.
dc.contributor.authorDoyle, Y.
dc.date.accessioned2011-06-08T13:37:14Z
dc.date.available2011-06-08T13:37:14Z
dc.date.issued2009
dc.identifier.citationOffredy , M , Rhodes , M & Doyle , Y 2009 , ' The anatomy, physiology and pathogenesis of a significant untoward incident ' , Quality in Primary Care , vol. 17 , no. 6 , pp. 415-421 .
dc.identifier.issn1479-1072
dc.identifier.otherPURE: 131403
dc.identifier.otherPURE UUID: ff2b9aff-d29c-444c-8f85-22310042d844
dc.identifier.otherdspace: 2299/5927
dc.identifier.otherScopus: 75149195384
dc.identifier.urihttp://hdl.handle.net/2299/5927
dc.descriptionOriginal article can be found at : http://www.ingentaconnect.com/ Copyright Radcliffe
dc.description.abstractThis paper provides a structured chronology of an investigation into a significant untoward incident in an elderly care ward. Using Reason's Swiss Cheese Model, which has become one of the dominant paradigms for analysing clinical and patient safety incidents, it charts the interplay of national and local policies resulting in unsafe practice. A qualitative approach was used in this multidimensional investigation. This approach aimed to discover what actually happened in the specific and related incidents and the underlying causes. Thus, the anatomy of the incident refers to the structure of staffing, the physiology includes the process in place at the time of the incident and the pathogenesis alludes to the development of the incident. The findings report on the patients involved in the incident. The investigation also explores how strategic financial directions from the Department of Health impact on staffing levels and training. These are contextualised using the concepts of the Swiss Cheese Model to assist understanding of how and why the incident occurred.en
dc.language.isoeng
dc.relation.ispartofQuality in Primary Care
dc.subjectprotection of vulnerable adults
dc.subjectrisk
dc.subjectsignificant untoward incident
dc.titleThe anatomy, physiology and pathogenesis of a significant untoward incidenten
dc.contributor.institutionDepartment of Adult Nursing and Primary Care
dc.description.statusPeer reviewed
rioxxterms.typeJournal Article/Review
herts.preservation.rarelyaccessedtrue


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