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Approach to Improving Safety
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BOOK/REPORT
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
NEWSPAPER/MAGAZINE ARTICLE
Organ donor's surgery death sparks questions.
Cohen E. CNN. April 9, 2012.
BOOK/REPORT
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
NEWSPAPER/MAGAZINE ARTICLE
'Never' land.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
COMMENTARY
Listen to the Family.
Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.
NEWSPAPER/MAGAZINE ARTICLE
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
NEWSPAPER/MAGAZINE ARTICLE
Reused devices, surgery's deadly suspects.
Klein A. The Washington Post. December 30, 2005:A3.
STUDY
Errors with concentrated epinephrine in otolaryngology.
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
BOOK/REPORTclassic
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
COMMENTARY
Developing a medication patient safety program — infrastructure and strategy.
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
NEWSPAPER/MAGAZINE ARTICLE
Disuse of system is cited in gaps in soldiers' care.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1. 
COMMENTARY
Drill down with root cause analysis.
McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.
COMMENTARY
OR Peeping.
Mackenzie CF. AHRQ WebM&M [serial online]. March 2004.
NEWSPAPER/MAGAZINE ARTICLE
USP initiatives for the safe use of medical gases.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
BOOK/REPORT
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
BOOK/REPORT
Health Care Comes Home: The Human Factors.
Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
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