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Approach to Improving Safety
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STUDY
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.
COMMENTARY
The Safe Tables Collaborative: a statewide experience.
Wagner CA, Cecchettini D, Fletcher J. Jt Comm J Qual Patient Saf. 2011;37:206-210.
MEETING/CONFERENCE PROCEEDINGS
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.
NEWSPAPER/MAGAZINE ARTICLE
Could it happen here? Learning from other organizations' safety errors.
Conway J. Healthc Exec. November/December 2008;23:64-67.
COMMENTARY
The competitive imperative of learning.
Edmondson AC. Harv Bus Rev. 2008;86:60-67, 160.
STUDY
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.
COMMENTARY
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.
STUDY
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.
REVIEW
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.
STUDY
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.
STUDY
What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.
BOOK/REPORT
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.
NEWSPAPER/MAGAZINE ARTICLE
Hospital takes a page from Toyota.
Connolly C. MSNBC News. June 3, 2005.
BOOK/REPORT
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.
NEWSPAPER/MAGAZINE ARTICLE
Arresting death: saving 100,000 lives.
Meyers S. Trustee. January 2007;60:6-10. 
STUDY
Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods.
Raab SS, Andrew-Jaja C, Condel JL, Dabbs DJ. Am J Obstet Gynecol. 2006;194:57-64.
BOOK/REPORTclassic
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
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