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Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Geneva, Switzerland: World Health Organization; July 2018. ISBN: 9789241513906.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
This collection of articles and case studies covers how health care organizations are working to establish and sustain a safety culture. The material includes discussions on the role of leadership, professionalism, and high reliability in improving work environments to support safety.
Philadelphia, PA: Pew Charitable Trusts; December 2017.
The usability of health information technologies (IT) is a key component to their safe effective use. This report introduces problems that surface due to poor design of health IT systems, summarizes expert opinion on the role of system usability in patient safety, and describes an approach to monitor and improve the safety of health IT by engaging multistakeholder collaboration.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.
Patient perspectives have been shown to identify otherwise undetected adverse events. This Institute for Healthcare Improvement–National Patient Safety Foundation commissioned survey, an update to their original 1997 survey, interviewed a probability-based sample of 2536 American adults. The results demonstrate the widespread nature of patient safety problems. Overall, 20% of respondents reported personally experiencing a medical error, most often in the outpatient setting. However, only 10% of respondents said they experienced harm when receiving medical care, which underscores the contrast between error and harm. The most common type of error was a missed or delayed diagnosis, followed by a communication error. About a third of errors were not reported. These results highlight the need to focus on diagnostic safety in the outpatient setting in order to improve patient safety in United States health care.
Washington, DC: National Quality Forum. September 19, 2017.
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitigating diagnostic error remains challenging. This National Quality Forum report describes the development of a framework to assist with measuring diagnostic quality and safety. The framework outlines 3 domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized measure concepts. High-priority areas for measure development include timeliness of diagnosis, timely follow-up of test results, communication and handoffs, patient-reported diagnostic errors, and patient experience related to diagnostic care. The committee also identified several cross-cutting themes and makes recommendations for researchers seeking to develop measures to improve diagnostic safety. A PSNet perspective discussed challenges and opportunities regarding diagnostic error.
Battles J; Azam I; Grady M; Reback K; Agency for Healthcare Research and Quality; AHRQ.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Dekker S. Boca Baton, FL: CRC Press; 2017.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Leadership has a responsibility to establish a culture that fosters staff and clinician well-being as a key component of patient safety. This white paper highlights the importance of enabling joy at work, reviews examples of organizations that have tested strategies to improve joy in work, and provides measurement tools to monitor the effect of initiatives over time. A past PSNet interview discussed joy in practice and physician professional satisfaction.
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 9781439830338
Human factors principles are widely applied in high-risk industries to promote safety and are increasingly adapted by health care organizations to improve patient safety. This book provides an in-depth analysis of the intersection of design and process with the human element of health care to underscore their effects on patient safety and introduce strategies for improvement. The authors cover a wide range of health care topics including medical technology and telemedicine. A past PSNet perspective discussed the application of human factors engineering concepts.

Shekelle PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Washington, DC: National Quality Forum; February 2016.
Health information technology (IT) has transformed health care and improved patient safety, but it has also led to unintended consequences that increase the risk for patient harm. This comprehensive report from the National Quality Forum aims to define and prioritize measures of health IT–related safety so that issues can be quantified and monitored over time. The report identifies nine priority areas for measurement, ranging from tracking the extent of system interoperability to clinical decision support to patient engagement. For each area, the authors recommend using a previously published framework to examine three domains: data considerations like availability and interoperability; technology–work system interaction, such as usability, training, governance, and safety monitoring; and application of health IT to make care safer. The committee proposes to hold health IT vendors, health care organizations, and clinicians accountable for specific safety metrics for health IT systems. Although these measures require further development and testing, this report lays the foundation for more systematically evaluating the safety gains and concerns associated with widespread health IT implementation.
Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available for free download on an open access platform. In the preface, the authors say the title reflects the fact that most current safety initiatives are focused on optimizing clinical processes or system improvements, which may succeed in a reasonably controlled environment. However, they sought to show how methods should be aimed at managing risks in the real, complex conditions of health care. The overall approach is oriented around examining safety from the patient's perspective and establishing patient safety as "the management of risk over time." There are separate chapters dedicated to safety strategies in hospitals, home care, and primary care. A prior PSNet interview with Charles Vincent discussed his career as one of the founders of the patient safety movement.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.