U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Diagnostic Errors (3)
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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.
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 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.
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.
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.
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.
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.
What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
Arresting death: saving 100,000 lives.
Meyers S. Trustee. January 2007;60:6-10.
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.
SPECIAL OR THEME ISSUE
The Failure Issue.
Harv Bus Rev. April 2011;89;1-140.
Does patient-centered design guarantee patient safety?: Using human factors engineering to find a balance between provider and patient needs.
France DJ, Throop P, Walczyk B, et al. J Patient Safety. 2005;1:145-153.
RHIOs aim to transform quality of care and patient safety.
van der Grinten P. Patient Safety & Quality Healthcare. May/June 2006;3:46-48.
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