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Learning from adverse events

Published online by Cambridge University Press:  02 January 2018

A. S. Zigmond
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“Experience is of no ethical value. It is merely the name men give to their mistakes” Oscar Wilde (The Picture of Dorian Grey).

Whenever colleagues meet it seems there is discussion about the latest inquiry into suicides or homicides. One cannot turn on the television without the news or a documentary referring to the latest tragedy. Risk assessment and defensible documentation are commonly the subjects of lectures and symposia. Lessons are learned, or not, from published inquiries and associated media attention. The attribution of blame is always high on the agenda. Yet when visiting psychiatric services and talking to staff I am usually impressed by their professionalism and staggered by their workload.

Type
Research Article
Information
Advances in Psychiatric Treatment , Volume 4 , Issue 5 , September 1998 , pp. 263 - 269
Copyright
Copyright © The Royal College of Psychiatrists 1998 

References

Blom-Cooper, L., Hally, H. & Murphy, E. (1995) The Falling Shadow: One Patient's Mental Health Care 1978–1993. London: Duckworth.Google Scholar
Department of Health (1995) The Health of the Nation. Building Bridges. London: HMSO.Google Scholar
Mental Health Act Commission (1997) Seventh Biennial Report. London: HMSO.Google Scholar
North East Thames & South East Thames Regional Health Authorities (1994) The Report of the Inquiry into the Care and Treatment of Christopher Clunis. London: HMSO.Google Scholar
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