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| 1. | Commentary: Diagnostic errors—The next frontier for patient safety. |
| | Newman-Toker DE, Pronovost PJ. JAMA. 2009;301:1060-1062. |
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| 2. |  Commentary: A piece of my mind. Copy-and-paste. |
| | Hirschtick RE. JAMA. 2006;295:2335-2336. |
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| 3. | Book/Report: When Things Go Wrong: Responding to Adverse Events. |
| | A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006. |
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| 4. | Commentary: Fixing healthcare from the inside, today. |
| | Spear SJ. Harv Bus Rev. September 2005;83:78-91. |
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| 5. | Commentary: Balancing "no blame" with accountability in patient safety. |
| | Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406. |
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| 6. | Study: Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. |
| | Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205. |
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| 7. | Book/Report: Keeping Patients Safe: Transforming the Work Environment of Nurses. |
| | Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004. |
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| 8. | Commentary: A hospitalization from hell: a patient's perspective on quality. |
| | Cleary PD. Ann Intern Med. 2003;138:33-39. |
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| 9. | Study: Diagnostic error in internal medicine. |
| | Graber ML, Franklin N, Gordon R. Arch Intern Med. 2005;165:1493-1499. |
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| 10. | Commentary: The wrong patient. |
| | Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833. |
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| 11. | Commentary: Errors, incidents and accidents in anaesthetic practice. |
| | Runciman WB, Sellen A, Webb RK, Williamson JA, Currie M, Morgan C. Anaesth Intensive Care. 1993;21:506-519. |
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| 12. | Image/Poster: Swiss Cheese Model. |
| | Reason J. Swiss cheese model. In: Reason J. Managing the Risks of Organizational Accidents. Burlington, VT: Ashgate Publishing Company; 2000. |
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| 13. | Commentary: Gaps in the continuity of care and progress on patient safety. |
| | Cook RI, Render M, Woods DD. BMJ. 2000;320:791-794. |
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| 14. | Commentary: Human error: models and management. |
| | Reason J. BMJ. 2000;320:768-770. |
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| 15. | Commentary: Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries. |
| | Gaba DM. Calif Manage Rev. 2000;43:1-20. |
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| 16. | Commentary: Risk mitigation in large scale systems: lessons from high reliability organizations. |
| | Grabowski M, Roberts KH. Calif Manage Rev. 1997;39:152-162. |
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| 17. | Commentary: Organizational culture as a source of high reliability. |
| | Weick KE. Calif Manage Rev. 1987;29:112-127. |
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| 18. | Commentary: Leading change: why transformation efforts fail. |
| | Kotter JP. Harv Bus Rev. Mar/April 1995;59-67. |
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| 19. | Study: Systems analysis of adverse drug events. |
| | Leape LL, Bates DW, Cullen DJ, et al; for the ADE Prevention Group. JAMA. 1995;274:35-43. |
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| 20. | Book/Report: Errors, Medicine, and the Law. |
| | Merry A, Smith AM. Cambridge, England: Cambridge University Press; 2001. |
