Toyota’s Quality Issues and Management Failure

Discuss About The Quality Promotion Through Health Management.

Management failure in the company and decline of quality led to recalling of already sold Toyota vehicles (Cole, 2011). Recalls of both new and old Prius and Lexus Toyota models was caused by safety concerns as a result of a variety of defects of the models. David Champion, the head of automotive testing, attests to this fact by noting quality defects in transmissions, brakes, squeal and rattles compounded with low quality of some materials of Toyota models (Koopman, 2014). The reduction in quality as stated by Toyota president, Akio Toyoda, is a misguided priority as the company embarked on targets for achieving high production to increase sales which led to quality compromise (Liker & Ogden, 2011). The production process was slowed down by four weeks, a new quality team of about one thousand engineers was instilled in Japan, and more quality response groups created globally as a measure to curb the low-quality issues in the company. Evidently, the agitated spirit to meet an increased daily target among workers possibly led to the omission of critical evaluations at every step of the production process to ascertain whether it adhered to all the quality guidelines. Toyota has gloried in a quality reputation as an ingrained attribute since implementing Deming’s theories and philosophies on quality control (Ciarniene & Vienazindiene, 2012). However, this seems to have been neglected as the market for Toyota products steadily grew across the globe.

The leadership of the company is to blame for the quality issues that challenged the company’s reputation. In 2005, Katsuaki Watanabe, former president of Toyota Company instituted a task force to handle customer complaints and reinforce quality control. However, the team was silently eliminated with a claim that it is not necessary since quality control was already ingrained in the company. The significance of the task force was ignored. However, it was essential to enforcing quality in the company. Furthermore, the management especially, high ranking executives ignored quality issues warnings from lower-ranking officials. The National Highway Traffic Safety Administration (NHTSA) had found a fault in Toyota’s electronic throttle control system and required the company to look into the problem (Kane et al., 2010). In regards to principles of risk management, the company failed to handle the safety issues to prevent future occurrence of the same.

Health care quality is the consideration of the level at which the society or people benefit from healthcare services. The assessment of healthcare is achieved through evaluation of patient satisfaction, the society’s well-being, diagnosis results and the medication process. These healthcare services should be accessible and affordable for patients. Therefore, healthcare quality is achieved at affordable costs (Luce, Bindman & Lee, 1994).The healthcare quality strikes a balance between quality improvement of healthcare services about patient needs and prevention of increase of expense for acquiring the services.

The Importance of Healthcare Quality Management

Improvement of health services is essential as it advances hospital conditions for effective hospital services (Luce, Bindmand & Lee, 1994). The primary objective is to enhance the provision of services that satisfy patient demands and needs. One of the healthcare satisfaction strategies is through the implementation of an integrated healthcare system that can cater for diverse patient needs. Moreover, quality services cannot be achieved without being accessible. Therefore, reforms for improving healthcare services aim at sustaining delivery of quality services while encouraging accessibility through reducing costs.

For the general well-being of the society, there is a need to improve healthcare services. Quality healthcare services guarantee a healthy community which in the long run enhances the living standards of the people as well as reduces the costs of living. Improved healthcare quality involves appropriate health advice which facilitates healthy living upon practicing the advice. So the improvement of health services is one way to a healthy population.

Leape et al. (2009) state that transparency, integration of healthcare, customer engagement, restoration of work sanity and educational reforms in the medical discipline are fundamental to achieving quality improvement in healthcare. Transparency, a moral obligation, will create a safety improvement culture encouraging honest information sharing amongst the healthcare givers, between the healthcare practitioners and the customers, between healthcare organizations and with the public. Clarity leads to the unification of efforts in the alleviation of health risks hence improving its quality since every stakeholder is well equipped with healthcare information.

Integrated healthcare services is an organizational model that fosters quality healthcare through consolidating all the systems involved in providing evidence-based (EB), befitting and responsive healthcare that is patient-centered. The primary goal of this condition is efficiency, safety, quality, and reliability to achieving excellent results at affordable prices.

Customer engagement involves the appreciation of the role of patients and their families in partnership to improve healthcare quality. Their voice matters in enhancing patient-centered services which are core to quality healthcare.

Providing quality healthcare is challenging, and without the caregivers feeling valued and finding the right mood for their work, they might fail to meet the demands effectively. There is need to formulate national policies and create a conducive working environment to motivate healthcare workers and keep them at their best to achieve quality healthcare. Both the government, the leadership of healthcare facilities and other stakeholders, should make this objective a priority.

Lastly, reformation of medical education to incorporate developmental skills, basic behaviors and attitudes required by physicians since not only the acquisition of scientific and clinical information are needed. The training should be interdisciplinary to prepare the students for future diverse healthcare problems.

Strategies for Improving Healthcare Quality

An Adverse Event (AE) is non-intentional harm or complicacy on a patient caused by healthcare management as opposed to underlying patient disease while undergoing a medication process that leads to prolonged hospitalization period, deaths or disability upon discharge (Thomas et al., 2000). AE is now a significant cause of deaths even more than breast cancer and AIDS do (Kohn, 1999). Moreover, they are a financial burden to the patient and their families as well as the governments.

According to de Vries et al. (2008) the most common AEs result from operational procedures and drug medication process whereby both contribute to 50% of the AEs. However, the operation-related cause is higher (39.6%) than drug related (15.1%). Surgical errors are those mistakes committed by the surgical team before, during and after an operation procedure and include all the types of surgeries. These errors range from inadequate diagnosis of the patient problem, wrong dosage and use of anesthetics, excessive bleeding, and improper stitching to poor recovery progress follow up.

The drug-related errors can occur at various stages of the medication process, that is, during ordering, transcription, dispensation, and administration. Also, wrong medication, inappropriate dosage and delays in medication process amount to drug-related mistakes. Poor judgment and improper communication can cause wrong therapy among the healthcare providers or between the pharmacist and the patient.

According to Wilson et al. (1999), the most common errors (34.6%) resulted from a failure in or complication of execution of an intended procedure which is referred to as system related. Also, inappropriate response to available information caused adverse events at 15.8% proportion. However, it is evident in both cases that medication errors are mostly human instigated as compared to system resultant.

From the above descriptions, there are variations on which is the most often cause of AEs. The differences can be attributed to the focus of the research as well as methodological differences in the classification of the AEs. For example, de Vries et al. (2008) categorizes medical errors basing on the type of procedure while to Wilson et al. (1999) identifies the causes of AEs on the system basis.

Almost half of the AEs are preventable while the others are not preventable (Thomas et al., 2000). Most of the errors that result from negligence and poor management are preventable. For example when a physician fails to examine a patient with rectal bleeding, the wrong diagnosis of acute appendicitis, misinterpretation of chest film, improper insertion of a catheter and perforation of the bowel during surgery (Leape et al., 1991). All these are avoidable when policies of strict adherence to professionalism are implemented to curb their occurrence. Some AEs cannot be prevented, for example, idiosyncratic reaction to drugs previously used, myocardial infarctions in patients without a history of heart disease, adhesive intestinal obstructions, adverse effects of radiation and bone marrow suppression due to drug use. These non-preventable AEs can maybe preventable as technology advances which leads to more knowledge about the AEs hence chances of the invention of control measures.

Report	Causes	Reasons
Bristol report (Inquiry & Kennedy, 2001)	The absence of quality control	The hospital system did not assess the standards of the healthcare services provided. There was no system to evaluate the doctors’ performance.
Lack of proper leadership and teamwork	There was poor communication between the high ranking and lower ranking management team and the role of each of them were not understood or stipulated. The poor communication hindered the capturing of mistakes that happened in the course of a therapeutic procedure. Most of the mistakes were unnoticed. The errors that could be observed were handled silently even without the management or other staff noticing. Teamwork was rare in this scenario which reduced chances of treating AEs with a consolidated approach.
Insufficient workforce and facilities	There were few full-time surgeons, few trained nurses and pediatric intensive care beds. The staff was overworked which contributed to the occurrence of AEs due to fatigue. The insufficient workforce could not manage to follow up on medication errors and come up with strategies to prevent future occurrence for they were overly preoccupied with daily duties. With the untrained nurses, there were high chances of the commission of errors.
Lack of quality control guidelines	It was not understood who is responsible for assessing the quality of the services and there lacked standards of performance. For this reason, errors that led to AEs were assumed for there was no one with the obligation to follow up on such cases.
Lack of transparency	Some of the concerns raised were silenced without any evidence of action. This invalidated the essence of reporting any errors for it could at the end be a waste of time. Lack of transparency discouraged the reporting of the mishaps.
Poor hospital organization	Poor healthcare provision systems and leadership structure. The interaction between hospital departments was poor. This amounted to poor communication and cooperation to avert the occurrence of medication mishaps. The leadership too did not provide an enabling environment or system to handle errors.
Bundaberg report (Harvey & Faunce, 2005)	The absence of sufficient credentialing system for healthcare workers	Wrong people end up being employed to handle human healthcare due to lack of employment policies or failure in implementation of such policies. Unqualified doctors were responsible for causing errors. The management was led by a doctor not quite qualified for the position. So, many of the critical situations and mistakes were not handled exposed the lack of expertise of the hospital management.
Insufficient performance monitoring and attention to complaints	The service of the doctors was not assessed, and iatrogenic adverse events were not scrutinized. Many errors were not reported to the management. Slackness crept into the system through the doctors since no one could make them accountable for their actions.
Defective licensing system for healthcare workforce	Poor registration guidelines will lead to employment of unqualified personnel.
Inadequate resources	Quality healthcare demands a lot of resources; a constrained budget led to poor quality services hence AEs. Moreover, the few funds available were channeled to equipping the hospital and not managing of errors.
Concealment culture	Services related problems were not openly handled for fear of bad reputation. Many errors were committed, but they were concealed and therefore blocking measures to check AEs.
Riveredge hospital reports (Atkins et al., 2003)	Inadequate treatment plans	The services offered did not meet all the patient needs. For example, medication error corrective measures were not part of the services provided in the facility.
Medication non-compliance	Concerns about not meeting medication standards were not addressed
Poorly trained staff	Undoubtedly such a team did not offer the recommended quality services to medically diverse problems presented by their customers
Ineffective monitoring	The staff was not assessed for quality compliance
Poor management and hospital system	For example, frequent transfers of patients from one unit to the other interrupted the healing process.
Inadequate resources	Led to early discharge of unfit patients to create room for incoming patients. The early release could does not allow for ample time to process the errors committed. Such a situation led to AEs. Resources required to handle and prevent an occurrence of errors were insufficient. This enhances increased chances of commission of errors.

Adverse Events in Healthcare

An adverse event can result from the failure of hospital personnel to follow laid down professional guidelines for a therapeutic process or be as a result of the lack of systems to prevent the occurrence of errors. Those that are due to personal attributes are regarded as an individual, and those blamed on the organization of the hospital are referred to as system errors. Both errors are preventable, but the reformation approach will differ as one will focus on improving professionalism among healthcare workers while the other will entail the restructuring of how hospital activities are carried out to prevent them from occurring. For example, an error due to improper drug dosage results from errors in measuring the correct medication quantities constituting an individual mistake while an adverse event as a result of lack of an outlined procedure of handling complaints is system caused. System errors can be prevented by restructuring the hospital leadership and their roles as well as the formulation of guidelines that restrict or manage adverse events. Individual errors will require creating a conducive environment for healthcare workers to enhance professionalism and reduce the chances of the doctors, pharmacist, and nurse committing mistakes during the medication process.

Most hospitals met the accreditation criteria since the policy focused on hospital facilities and services as opposed to quality of the services provided. So, the healthcare facilities got accreditation for having attained the requirements pertaining the types of services they offered and how well equipped they were in providing those services. However, the point of considering how the management structure could affect the quality of services was not in question. Furthermore, some quality control measures did not feature in the accreditation process. Therefore, the vetting process for accreditation of the facilities could not notice the issues that the inquiry commissions found since their scope was limited to answering the question of whether the hospital can offer the intended services. But, the inquiry teams focused on both individual and system actors that led to adverse events, unlike the accreditation process that handled only system licensing.

General hearings are achieving “not much” success since few reforms are implemented mainly on a short-term basis to win back the trust of the public (Vize, 2017). The inquiries put forth recommendations basing on their findings but do not consider the practicability of the proposals which later prove strenuous to the hospital management for implementation. For example, the employment of enough clinicians is a probable recommendation from such inquiries, but the facilities are financially incapacitated to implement such a proposal fully.    According to Newdick & Danbury (2015), the implementation of the reforms as proposed by inquiries have realized no success. In most cases, there is evidence of some system changes, but individual behavior reformation of the healthcare facilities employees have been overlooked. Maybe it is because behavioral changes are complicated to establish. For example, it is difficult to impart compassion, a crucial factor to quality healthcare in nursing, on the nurses. Therefore, the practicability impossibilities of some proposals of the inquiry reports are responsible for the slow quality improvement of the facilities in question.

Radhakrishna (2015) defines a blame-free culture as a system that encourages information input, analysis of the data and response to errors without fear of punishment of those involved. The blame put on individuals that commit errors focuses on the person that errored and not the system that contributed to the mistakes. The aftermath is psychological harm to the professional which affects the performance of the individual sometimes it has resulted in suicides. The blame culture does not eliminate errors since it hinders honest and transparent response to such mistakes. Blame free culture identifies the errors and assesses the cause transparently and finds a solution as well as strategies to prevent future occurrences. In fact, by handling a mistake in blame-free approach, many healthcare professionals get motivated and become better as the others gather lessons from the experience to eliminate errors in the system.

The blame-free culture focuses on avoiding stigmatization on healthcare professionals by considering system failure. There is a shift of attention from the person who committed the error and the mistake itself to the system that cultivated the mishap. In this case, the blame-free culture is still blameworthy, that is either the system or the individual is to blame. Contrary, the just culture involves the creation of open, fair and learning culture. Also, it is about designing safer systems and the management of behavioral choices to avoid human errors and consequently adverse events (Delbanco et al., 2007).

The understanding of the difference between the two is vital since it separates a habit of observing problems and fixing them to perceiving occurrence of errors as an opportunity to improve the understanding of the risks which is crucial in avoidance of future mistakes (Wachter & Pronovost, 2009). The just culture is a strong safety culture that requires the participation of all the healthcare stakeholders in assuring patient safety unlike when only the involved people attend to the problem.

The traditional approaches focus on errors and procedural violations by healthcare professionals. The plan assumes the errors are purely a deviation from the standard mental process such as forgetfulness, inappropriate attention, poor motivation, negligence, carelessness or recklessness. The consequences of such errors instill stigma among the culprits since they involve disciplinary actions, litigation threats, blames and shaming (Reason, 2000). In this case, all the blame goes to the individual who committed the errors since the traditional approaches treat the failures as a human weakness. In the end, the involved individual suffers the consequences alone, and no insight is taken into averting future errors by obtaining lessons from the incidence.

The disciplinary actions are made, and blame upon the doctors who commit medication errors that result to AEs causes self-blame among healthcare professionals. The self-blame is as a result of incrimination from the management and healthcare authorities. The doctors develop a feeling of the blame since they were involved in the commission of the error. Just as the system approaches the matter, the doctors feel responsible for the bad reputation and other related adverse effects resulting from AEs. Furthermore, the method of handling the errors is criminative in that the objective to find someone responsible for facing charges. The focus is only on the individual so in this case, the doctor acknowledges self-blame to show regret for the mishap. The self-blame is detrimental to the performance and psychological well-being of the doctors. Self-blame leads to low work output and reduction in quality of the services. Therefore, the management of the healthcare facilities must protect its staff from a self-blame system by reforming the process of identifying and solving errors within their facilities.

Reporting and response to therapeutic mistakes requires an open culture to be productive. For quality improvement, there is need to learn from previous experiences. For this to be effective, reliable system of reporting for the occurrence of mistakes should be put in place for all the errors to be captured. The hospital management should make the doctors understand the significance of such mishaps and the essence of reporting them. The next step is transparency in dealing with the mistakes which assure those reporting that always an appropriate action will follow after the report.

The management should cultivate a culture of proper communication among hospital employees, between themselves and the patients. Some of the errors result from insufficient information due to communication breakdown. A just culture requires teamwork through sharing of information and good relation amongst the workers. Therefore for quality management to enhance a “just” culture, there must be free interaction and information flow in the hospital environment (Walshe & Shortell, 2004).

Evidence-based practice (EBP) is the conscionable, particular and intelligent application of current evidence in decision making regarding the care of patients (Gambrill, 2006). The aim of using EBP is to achieve improved healthcare and improve patient satisfaction at low costs. Also, EBP involves the integration of personal expertise with other best clinical evidence from systematic research (Sackett et al., 1996).

EBP enhances quality healthcare through identification of the most effective remedy to a medical problem. Marshall (1992) highlights that American studies have indicated that library support for physicians has reduced patient care costs, the number of patient admissions, hospitalization period and enhanced quality improvement in decision making, advising patients and safes on time for the medication process. Individual professionalism is key to any medical practice. However, there is need to be up to date with healthcare information since medical problems are diverse and keep on evolving. Therefore, EBP which incorporates the aforementioned critical components to improve health care has proved crucial for the healthcare expertise. Availability of extensive knowledge enhances proper judgment leading to quality services because an appropriate action, for example, the best medication to a health problem is achieved. When the best remedy is given to patients, there are high chances of recovery which ultimately encourages quick healing, reduces costs of medication and prevents future admissions for a similar issue.

However, the importance of the application of EBP is faced with a limitation of variations in that it results in the inconsistency of healthcare provision (Cutler, 2005). There has been some deviation in the effectiveness and quality of medical care. The resultant cases are inequality healthcare access and escalating healthcare costs due to the application of varied scientific information. Such a problem has been exposed through epidemiological research on local medical practice variation in America. Different types of interventions for a similar problem have been carried out in different geographical areas of America. Such modification invalidates therapeutic efficiency as they affect the quality of healthcare. There is a need for profiling of scientific based solution for medical and surgical treatments for various populations to achieve consistency and quality healthcare improvement.

One of the criticisms to EBP is that it is incoherent with current realities as highlighted by Mitchell (2013). She further argues that nursing practices involve the use of techniques and technologies and knowledge from EBP is not technical. Nursing practice has guidelines and procedures formulated by multidisciplinary groups which have the responsibility to update clinical training in various medical specialties. Therefore, as much as clinicians can use EBP in their practice, it is not the only way of assessing quality practice and improvement of services.

Patient-centered healthcare is healthcare service that is respected and is responsive to patient or customer values, needs and preferences (Australian Commission on Safety and Quality in Health Care, 2011). The approach treats patients as individual human beings as opposed to being perceived as a condition in need of medication.

The Institute of Medicine (IOM) endorses customer-centered care a crucial factor in the provision of quality healthcare (Corrigan, Swift & Hurtado, 2001). The model facilitates consultation and information sharing between the physicians and the patients. In this case, the patient gains information on available options for the intervention of a particular problem and chooses a befitting one based on preferences. The customer satisfaction needs are the priority of the medication process. Through this approach, many errors are avoided, and patients suggest ideas that will improve the quality of healthcare services.

The general wellbeing of the society is boosted. Patient-centered healthcare ensures exchange of health-related information that improves the health of the nation upon practice or implementation. Furthermore, there is enhanced access to reliable health advice as the patients get connected to the healthcare providers through information sharing as their health confidants. Effective treatment is also achieved as trusted professionals administer therapy to their patients.

Inadequate medical staff derails patient care centeredness due to lack of comprehensive consultation and expected attention from the understaffed healthcare team. For the satisfaction of every patient need, it is crucial that each is accorded enough time and recognition. When the number of the patients and that of the medical professionals isn’t proportional, then some procedure has to be left out in the process of attending to some patients to help the others in line. Even follow up activities are not comprehensively carried out due to time and a high number of patients to be served within a limited time.

Another critical factor to patient-centered healthcare provision is culture. In this regard factors associated with culture such as language can act as a barrier to effective implementation of patient-centered healthcare (Beach, Saha & Cooper, 2006). There are cultural diversities among various population each with unique demands all of which have to be met by the healthcare providers to achieve the desired satisfaction. Understanding and acknowledging that there are diverse cultural norms is vital to quality service. However, care should be taken to avoid stereotyping which may lead to an inappropriate assumption about specific ethnic groups. Therefore, a cross-cultural approach is the most appropriate model for satisfying culturally diverse patients.

Clinical governance is a set of efforts aimed at facilitating care and promoting a productive culture and environment within which the responsibility can flourish (Braithwaite & Travaglia, 2008). Clinical governance also entails the integration of systems to ensure clinical responsiveness and accountability with the objective of improving the quality and safety of healthcare services. Clinical governance frameworks require designs and process that incorporates economic control, service delivery performance and clinical excellence to enhance services through engaging clinicians. So, clinical governance is a cultural change towards knowledge and interdependence in leadership and systems to improve the quality of healthcare and patient safety (Laubscher, 2008).

Effective clinical governance depends on the context of the application. Various hospitals have a unique management structure. Change of leadership culture requires the understanding of the already existing structure for appropriate recommendations. Therefore, the successful application of such a healthcare quality reform will depend on the leadership structure of the facility, which varies from one hospital to the other. Therefore, enabling leadership design enhances the establishment of clinical governance as opposed to an ineffective leadership that dwindles efforts for healthcare improvement.

The implementation of clinical governance has been affected by barriers which require reformations in policy and the participation of all hospital professionals to overcome. Gauld & Horsburgh (2015) highlight knowledge and attitude, culture and organizational factors as hindrances of clinical governance. The inadequacy of clinical governance knowledge among many clinicians contributes to the wrong attitude towards this strategy.  In some cases, the clinicians have no clue to what CG is, making it burdensome for them when they are called upon to facilitate its implementation. In contrast, most managers have the required information about this strategy. The application of CG requires a positive attitude and substantial knowledge for it to achieve its objectives. The informed manager should communicate to the other clinicians and bring them on board as they are made to understand their role in attaining CG goals through its establishment. Moreover, training can be organized to create a learning and exchange platform about clinical governance.

Some retrogressive cultures such as lack of teamwork and transparency in many healthcare facilities undermine the efforts of implementing clinical governance. Partnership enhances the generation of new ideas and consolidates efforts to improve the realization of CG goals. Change is always faced with the opposition before it becomes a norm in a given society, in this case, a healthcare facility. Prior training and communication will help curb the anticipated objections. In some cases, the managerial team has a weak connection with the other staff resulting in poor coordination. Such cases are typical where he managers disregard the other employees who bring about uncooperativeness in implementing of policies guided by the management. A culture that embraces change and CG should be taught among hospital employees. 

Hospital management designs sometimes prevent the implementation of CG. Some facilities have a managerial organization that belittles other staff. For example, before a junior staff member gets to the top management, he or she has to go through different offices before talking to the manager. This organizational structure creates gaps between various departments within the facility. Such leadership hinders clinical governance for it makes it hard for the other staff to freely interact with the administration which is a critical factor in the establishment of CG.

Leaders face challenges in attaining the change in their institution due to insufficient resources and support systems. As the leaders are tasked with implementing CG policies, they can achieve little if they are not empowered through resource provision from the relevant stakeholders.

In conclusion, management is key to quality service provision in any organization. There may be reasonable reforms however they are of non-effect due to poor management. There are management applicable lessons to be learned from other industries that can benefit the healthcare sector in improving the quality of therapeutic services. Evidently, healthcare stakeholders must participate and possess the right attitude to enhance implementation of policies that are aimed at improving the quality of healthcare services. The process of advancing quality care requires periodical review to evaluate progress and to improve quality. Medication errors are both individual and system resultant. Most of these errors are preventable depending on the approach used to manage them. The leadership of healthcare facilities should be committed to creating a “just culture” and eradicate the blame-culture that is detrimental to the management of adverse events. Resources are necessary to enhance the establishment of excellence in service delivery.

References

Atkins, M. S., Graczyk, P. A., Frazier, S. L., & Abdul-Adil, J. (2003). Toward a new model for promoting urban children’s mental health: Accessible, effective, and sustainable school-based mental health services. School psychology review, 32(4), 503-515.

Australian commission on Safety and Quality in Health Care (2011). Patient-centered care: Improving quality and safety through partnership with patients and consumers, ACSQHC, Sydney.

Beach, M. C., Saha, S., & Cooper, L. A. (2006). The role and relationship of cultural competence and patient-centeredness in health care quality (Vol. 36). New York, NY: Commonwealth Fund.

?iarnien?, R., & Vienažindien?, M. (2012). Lean manufacturing: theory and practice. Economics and management, 17(2), 726-732.

Cole, R. E. (2011). What really happened to Toyota?. MIT Sloan Management Review, 52(4), 29.

Corrigan, J. M., Swift, E. K., & Hurtado, M. P. (Eds.). (2001). Envisioning the national health care quality report. National Academies Press.

Cutler, D. M. (2005). Your money or your life: Strong medicine for America’s health care system. Oxford University Press.

de Vries, E. N., Ramrattan, M. A., Smorenburg, S. M., Gouma, D. J., & Boermeester, M. A. (2008). The incidence and nature of in-hospital adverse events: a systematic review. BMJ Quality & Safety, 17(3), 216-223.

Delbanco, T., & Bell, S. K. (2007). Guilty, afraid, and alone—struggling with medical error. New England Journal of Medicine, 357(17), 1682-1683.

Gambrill, E. (2006). Evidence-based practice and policy: Choices ahead. Research on Social Work Practice, 16(3), 338-357.

Gauld, R., & Horsburgh, S. (2015). Healthcare professionals’ perceptions of clinical governance implementation: a qualitative New Zealand study of 3205 open-ended survey comments. BMJ open, 5(1), e006157.

Harvey, K., & Faunce, T. (2005). A critical analysis of overseas-trained doctor (OTD) factors in the bundaberg base hospital surgical inquiry. Law Context: A Socio-Legal J., 23, 73.

Inquiry, B. R. I., & Kennedy, I. (2001). the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. Stationery Office.

Kane, S., Liberman, E., DiViesti, T., & Click, F. (2010). Toyota sudden unintended acceleration. Safety Research & Strategies.

Kohn, L. T. (1999). Committee on Quality of Health Care in America, Institute of Medicine. To err is human: building a safer health system, 188-238.

Koopman, P. (2014). A case study of Toyota unintended acceleration and software safety. Presentation. Sept.

Laubscher, H. (2008). Clinical governance in the hospital environment. South African Pharmaceutical Journal, 75(2).

Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., … & Hiatt, H. (1991). The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. New England journal of medicine, 324(6), 377-384.

Leape, L., Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., … & Pinakiewicz, D. (2009). Transforming healthcare: a safety imperative. BMJ Quality & Safety, 18(6), 424-428.

Liker, J. K., & Ogden, T. (2011). Toyota under fire. McGraw-Hill Professional.

Marshall, J. G. (1992). The impact of the hospital library on clinical decision making: the Rochester study. Bulletin of the Medical Library Association, 80(2), 169.

Mitchell, G. J. (2013). Implications of holding ideas of evidence-based practice in nursing. Nursing science quarterly, 26(2), 143-151.

Newdick, C., & Danbury, C. (2015). Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire. Journal of medical ethics, 41(12), 956-962.

Radhakrishna, S. (2015). Culture of blame in the National Health Service; consequences and solutions.

Reason, J. (2000). Education and debate: human error: models and management. British Medical Journal, 320, 7237.

Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t.

Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T., Williams, E. J., … & Brennan, T. A. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical care, 38(3), 261-271.

Vize, R. (2017, September 20). There’s a long list of NHS inquiries, but what have they actually changed? Retrieved from https://www.theguardian.com/healthcare-network/2016/mar/04/national-health-service-nhs-inquiries-what-have-they-changed

Wachter, R. M., & Pronovost, P. J. (2009). Balancing “no blame” with accountability in patient safety. N Engl J Med, 361(14), 1401-1406.

Walshe, K., & Shortell, S. M. (2004). When things go wrong: how health care organizations deal with major failures. Health Affairs, 23(3), 103-111.

Wilson, R. M., Harrison, B. T., Gibberd, R. W., & Hamilton, J. D. (1999). An analysis of the causes of adverse events from the Quality in Australian Health Care Study. The Medical Journal of Australia, 170(9), 411-415.