McLean Jenny, Walsh Michael
Strategic and Special Projects, Bayside Health.
Aust Health Rev. 2003;26(1):12-23. doi: 10.1071/ah030012.
The Douglas Inquiry investigated the Obstetrics and Gynaecological services at King Edward Memorial Hospital from 1990-2000. Performance deficiencies were identified at state, board and hospital level contributing to poor outcomes for women, babies and families. The Inquiry raises important issues about clinical governance, leadership and culture, accountability and responsibility, safety and quality systems, staff support and development, and concern for patients and their families. The King Edward, Bristol and Royal Melbourne Hospital inquiries reveal important similarities and key lessons for governments, health care leaders and providers. The health care industry must ensure effective clinical governance supporting a culture of inquiry and open disclosure, and must build rigorous systems to monitor and improve health care safety and quality.
道格拉斯调查研究了1990年至2000年期间爱德华国王纪念医院的妇产科服务。在州、委员会和医院层面都发现了绩效缺陷，这些缺陷导致妇女、婴儿和家庭的不良结局。该调查提出了有关临床治理、领导力和文化、问责制和责任、安全与质量体系、员工支持与发展以及对患者及其家庭的关怀等重要问题。对爱德华国王医院、布里斯托尔医院和皇家墨尔本医院的调查揭示了对政府、医疗保健领导者和提供者而言重要的相似之处和关键教训。医疗保健行业必须确保有效的临床治理，以支持探究和公开披露的文化，并且必须建立严格的系统来监测和改善医疗保健安全与质量。
