U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Diagnostic Errors (3)
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Discontinuities, Gaps, and Hand-Off Problems (3)
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Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.
Kennerly DA, Saldaña M, Kudyakov R, da Graca B, Nicewander D, Compton J. J Patient Saf. 2013;9:87-95.
The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?
Hofmann PB. Healthc Exec. 2012 May-Jun;27:64,66-67.
The Safe Tables Collaborative: a statewide experience.
Wagner CA, Cecchettini D, Fletcher J. Jt Comm J Qual Patient Saf. 2011;37:206-210.
Patient Safety as an Exercise in Behavioral Change.
Leape LL. Social and Behavioral Sciences in Action. Washington, DC: National Research Council of the National Academies. September 24, 2012.
Could it happen here? Learning from other organizations' safety errors.
Conway J. Healthc Exec. November/December 2008;23:64-67.
The competitive imperative of learning.
Edmondson AC. Harv Bus Rev. 2008;86:60-67, 160.
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.
The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.
Kerfoot KM, Rapala K, Ebright P, Rogers SM. J Nurs Adm. 2006;36:582-588.
Active learning: when is more better? The case of resident physicians' medical errors.
Katz-Navon T, Naveh E, Stern Z. J Appl Psychol. 2009;94:1200-1209.
Effects of learning climate and registered nurse staffing on medication errors.
Chang Y, Mark B. Nurs Res. 2011;60:32-39.
Safety and risk management interventions in hospitals: a systematic review of the literature.
Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Med Care Res Rev. 2009;66(suppl 6):90S-119S.
The relationship between organizational leadership for safety and learning from patient safety events.
Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.
What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
Seven Leadership Leverage Points for Organization-Level Improvement in Health Care.
Reinertsen JL, Bisognano M, Pugh MD. 2nd ed. Cambridge, MA: Institute for Healthcare Improvement; 2008.
Hospital takes a page from Toyota.
Connolly C. MSNBC News. June 3, 2005.
Fostering Organizational Learning: The Impact of Work Design on Workarounds, Errors, and Speaking Up About Internal Supply Chain Problems.
Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. HBS Working Paper No. 13-044.
Arresting death: saving 100,000 lives.
Meyers S. Trustee. January 2007;60:6-10.
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Sorensen AV, Bernard SL. Jt Comm J Qual Patient Saf. 2012;38:89-95.
Event reporting: the value of a nonpunitive approach.
Youngberg BJ. Clin Obstet Gynecol. 2008;51:647-655.
Housestaff and medical student attitudes toward medical errors and adverse events.
Vohra PD, Johnson JK, Daugherty CK, Wen M, Barach P. Jt Comm J Qual Patient Saf. 2007;33:493-501.
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