Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management

J T Reason; J Carthey; M R de Leval

doi:10.1136/qhc.0100021..

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Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management

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	Abstract	Full	Pdf
Nov 2001	37	51	8
Dec 2001	15	25	3
Jan 2002	16	49	8
Feb 2002	1	7	0
Mar 2002	0	6	0
May 2002	21	84	72
Jun 2002	11	49	46
Jul 2002	4	71	41
Aug 2002	17	39	19
Sep 2002	3	18	1
Oct 2002	5	21	10
Nov 2002	10	21	5
Dec 2002	2	7	3
Jan 2003	8	19	8
Feb 2003	9	25	8
Mar 2003	7	20	11
Apr 2003	15	41	13
May 2003	10	28	2
Jun 2003	8	32	9
Jul 2003	12	104	20
Aug 2003	25	218	4
Sep 2003	8	29	8
Oct 2003	10	97	13
Nov 2003	24	30	11
Dec 2003	23	31	7
Jan 2004	17	77	11
Feb 2004	16	210	13
Mar 2004	17	41	9
Apr 2004	20	21	11
May 2004	23	37	8
Jun 2004	40	50	40
Jul 2004	39	77	41
Aug 2004	51	83	26
Sep 2004	38	74	27
Oct 2004	20	90	39
Nov 2004	15	68	48
Dec 2004	14	45	35
Jan 2005	13	57	40
Feb 2005	9	65	57
Mar 2005	17	70	34
Apr 2005	20	64	47
May 2005	14	84	51
Jun 2005	20	73	31
Jul 2005	13	59	29
Aug 2005	25	60	44
Sep 2005	15	55	29
Oct 2005	29	80	37
Nov 2005	23	47	28
Dec 2005	18	51	32
Jan 2006	10	45	22
Feb 2006	20	68	40
Mar 2006	16	45	42
Apr 2006	9	53	42
May 2006	11	63	51
Jun 2006	20	43	39
Jul 2006	13	45	31
Aug 2006	16	47	38
Sep 2006	33	42	71
Oct 2006	20	76	64
Nov 2006	15	45	57
Dec 2006	11	28	42
Jan 2007	19	55	76
Feb 2007	19	68	47
Mar 2007	14	43	51
Apr 2007	91	28	44
May 2007	85	27	49
Jun 2007	57	23	36
Jul 2007	65	26	39
Aug 2007	63	22	27
Sep 2007	70	13	21
Oct 2007	64	23	26
Nov 2007	41	17	24
Dec 2007	46	20	15
Jan 2008	78	24	38
Feb 2008	68	14	23
Mar 2008	83	31	52
Apr 2008	105	29	37
May 2008	84	15	31
Jun 2008	81	18	25
Jul 2008	80	12	18
Aug 2008	66	15	30
Sep 2008	77	19	34
Oct 2008	63	22	27
Nov 2008	37	7	9
Dec 2008	44	7	16
Jan 2009	56	18	28
Feb 2009	65	18	29
Mar 2009	73	27	35
Apr 2009	69	8	21
May 2009	56	30	25
Jun 2009	56	14	23
Jul 2009	51	10	22
Aug 2009	64	15	19
Sep 2009	74	15	32
Oct 2009	60	23	16
Nov 2009	14	15	8
Dec 2009	13	4	9
Jan 2010	57	20	15
Feb 2010	71	18	37
Mar 2010	69	26	27
Apr 2010	85	19	21
May 2010	85	36	31
Jun 2010	45	23	20
Jul 2010	45	22	13
Aug 2010	97	26	20
Sep 2010	137	29	25
Oct 2010	131	26	17
Nov 2010	106	35	15
Dec 2010	72	28	14
Jan 2011	42	13	18
Feb 2011	93	25	19
Mar 2011	120	14	28
Apr 2011	83	15	28
May 2011	115	12	26
Jun 2011	100	15	15
Jul 2011	86	13	10
Aug 2011	72	10	4
Sep 2011	76	8	16
Oct 2011	91	12	23
Nov 2011	88	47	18
Dec 2011	65	88	29
Jan 2012	56	86	24
Feb 2012	54	71	29
Mar 2012	62	78	19
Apr 2012	68	85	26
May 2012	83	85	32
Jun 2012	87	86	30
Jul 2012	70	62	31
Aug 2012	61	64	28
Sep 2012	70	44	34
Oct 2012	103	55	30
Nov 2012	101	40	28
Dec 2012	78	49	18
Jan 2013	71	51	25
Feb 2013	98	76	21
Mar 2013	136	85	43
Apr 2013	94	59	30
May 2013	164	84	27
Jun 2013	51	28	15
Jul 2013	87	28	18
Aug 2013	74	11	8
Sep 2013	99	20	23
Oct 2013	101	34	31
Nov 2013	106	29	26
Dec 2013	39	23	28
Jan 2014	63	30	33
Feb 2014	92	45	24
Mar 2014	102	36	27
Apr 2014	99	41	39
May 2014	97	54	38
Jun 2014	72	22	19
Jul 2014	82	26	18
Aug 2014	80	24	15
Sep 2014	87	28	64
Oct 2014	97	27	30
Nov 2014	86	37	24
Dec 2014	62	12	23
Jan 2015	98	69	37
Feb 2015	81	75	45
Mar 2015	135	60	41
Apr 2015	78	26	27
May 2015	79	23	78
Jun 2015	74	14	69
Jul 2015	89	30	91
Aug 2015	81	17	119
Sep 2015	89	34	72
Oct 2015	67	27	37
Nov 2015	71	25	21
Dec 2015	61	36	14
Jan 2016	75	58	80
Feb 2016	84	35	35
Mar 2016	90	44	19
Apr 2016	100	50	35
May 2016	78	138	26
Jun 2016	76	20	19
Jul 2016	71	22	23
Aug 2016	91	24	36
Sep 2016	97	20	58
Oct 2016	140	54	38
Nov 2016	96	46	26
Dec 2016	69	109	26
Jan 2017	76	79	18
Feb 2017	79	43	31
Mar 2017	76	37	33
Apr 2017	58	55	26
May 2017	69	67	27
Jun 2017	48	54	20
Jul 2017	79	44	26
Aug 2017	77	37	19
Sep 2017	176	80	15
Oct 2017	217	71	39
Nov 2017	193	75	14
Dec 2017	142	50	24
Jan 2018	119	64	14
Feb 2018	91	83	9
Mar 2018	128	127	25
Apr 2018	115	115	52
May 2018	95	95	32
Jun 2018	63	65	20
Jul 2018	82	82	20
Aug 2018	77	77	24
Sep 2018	76	76	25
Oct 2018	108	108	19
Nov 2018	108	104	24
Dec 2018	118	118	18
Jan 2019	95	93	23
Feb 2019	128	89	27
Mar 2019	100	43	31
Apr 2019	124	78	38
May 2019	127	57	49
Jun 2019	79	40	32
Jul 2019	69	30	37
Aug 2019	73	31	22
Sep 2019	88	51	28
Oct 2019	100	39	15
Nov 2019	96	26	14
Dec 2019	59	29	16
Jan 2020	62	16	19
Feb 2020	87	33	12
Mar 2020	70	26	20
Apr 2020	73	25	26
May 2020	55	18	11
Jun 2020	49	17	11
Jul 2020	85	57	40
Aug 2020	67	17	10
Sep 2020	82	33	17
Oct 2020	98	35	21
Nov 2020	66	16	12
Dec 2020	64	16	20
Jan 2021	58	18	13
Feb 2021	82	34	12
Mar 2021	87	39	15
Apr 2021	84	14	15
May 2021	79	35	25
Jun 2021	30	30	6
Jul 2021	30	30	16
Aug 2021	25	22	14
Sep 2021	12	10	9
Oct 2021	102	33	26
Nov 2021	71	23	21
Dec 2021	71	28	21
Jan 2022	79	32	11
Feb 2022	79	37	8
Mar 2022	108	57	12
Apr 2022	79	30	13
May 2022	107	49	10
Jun 2022	78	46	6
Jul 2022	73	52	5
Aug 2022	95	54	7
Sep 2022	106	31	19
Oct 2022	101	50	13
Nov 2022	107	28	35
Dec 2022	119	63	15
Jan 2023	87	42	10
Feb 2023	118	58	24
Mar 2023	130	73	20
Apr 2023	88	28	25
May 2023	56	20	9
Jun 2023	67	29	8
Jul 2023	90	35	29
Aug 2023	75	28	10
Sep 2023	68	36	6
Oct 2023	159	56	23
Nov 2023	107	37	30
Dec 2023	249	20	5
Jan 2024	77	15	1
Feb 2024	175	9	6
Mar 2024	136	10	0
Total	18315	11548	6915

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