Accident investigation is widely used to learn from adverse events occurring in industry. The conclusions of such investigations are typically used to inform the design and function of socio-technical systems and organisational management. This tradition is less well developed in healthcare, though evidence is growing that similar approaches may be applicable. The first part of the thesis reports a systematic review and evaluation of methods for the investigation of incidents in healthcare with further work then conducted to pilot an approach in primary and community care settings. The second part of the thesis describes the application of the approach within the framework of a study designed to understand the problem of medication related admissions in older people. The research maps the epidemiology of the problem and then moves beyond it through depth investigations of individual cases. The methods selected have provided an opportunity to understand the immediate and the contributory causes of adverse medication related events in older people. More particularly, the approach provided a framework for understanding general practice as a whole system, where there are interactions between people, processes and policies that can bring untoward consequences. This level of understanding of general practice identifies broader themes that characterise the organisation of primary care and point to areas for development that could bring substantial benefits to patients in the care they receive.
| Identifer | oai:union.ndltd.org:bl.uk/oai:ethos.bl.uk:631759 |
| Date | January 2007 |
| Creators | Rogers, S. |
| Publisher | University College London (University of London) |
| Source Sets | Ethos UK |
| Detected Language | English |
| Type | Electronic Thesis or Dissertation |
| Source | http://discovery.ucl.ac.uk/1444077/ |
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