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COMMENTARY
Root cause analysis.
Stecker MS. J Vasc Interv Radiol. 2007;18:5-8.
STUDY
Resident fatigue: is there a patient safety issue?
Mitchell CD, Mooty CR, Dunn EL, Ramberger KC, Mangram AJ. Am J Surg. 2009;198:811-816.
COMMENTARYclassic
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
PRESS RELEASE/ANNOUNCEMENT
Patient controlled analgesia by proxy.
The Joint Commission. Sentinel Event Alert. December 20, 2004;(33):1-2.
MULTI-USE WEBSITEclassic
Sentinel Event.
The Joint Commission.
STUDY
Utility of an online medication-error-reporting system.
Savage SW, Schneider PJ, Pedersen CA. Am J Health Syst Pharm. 2005;62:2265-2270.
NEWSPAPER/MAGAZINE ARTICLE
Sarasota Memorial Hospital reviewed after restrained patient dies.
Gulliver D. Sarasota Herald Tribune. November 7, 2006:BS1.
BOOK/REPORT
Adverse Health Events in Minnesota: Ninth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2013.
BOOK/REPORT
4th Ed. Patient Safety Essentials for Health Care.
Oakbrook Terrace, IL; Joint Commission on Accreditation of Healthcare Organizations; 2006. ISBN: 0866889892.
STUDYclassic
Sentinel events. In memory of Ben—a case study.
Haas D. Jt Comm Perspect. March/April 1997;17:12-15.
STUDY
Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.
Szekendi MK, Barnard C, Creamer J, Noskin GA. Jt Comm J Qual Patient Saf. 2010;36:3-9, AP1-AP2.
BOOK/REPORT
What Every Health Care Organization Should Know about Sentinel Events.
McKee J, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2005. ISBN: 0866889116.
AWARD RECIPIENT
Building and sustaining a systemwide culture of safety.
Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke G, Merti GE. Jt Comm J Qual Patient Saf. 2005;31:684-689.
COMMENTARY
Drill down with root cause analysis.
McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.
NEWSPAPER/MAGAZINE ARTICLE
State starts project to track serious hospital mistakes.
Colburn D. The Oregonian. February 1, 2006:B1.
COMMENTARY
Patient safety: what is really at issue?
Bagian JP. Front Health Serv Manage. Fall 2005;22:3-16.
AWARD RECIPIENT
MITSS HOPE Award.
Medically Induced Trauma Support Services.
NEWSPAPER/MAGAZINE ARTICLE
Benefits and risks of including patients on RCA teams.
ISMP Medication Safety Alert! Acute Care Edition. June 5, 2008;13:1-3.
STUDY
Injection practices among clinicians in United States health care settings.
Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.
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