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1 - 20 of 41
Ruskin KJ; Stiegler MP; Rosenbaum SH; Oxford University Press; OUP.
The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Boston, MA: Institute for Healthcare Improvement; 2019.
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.
Royal College of Surgeons of England; RCS.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
Complex systems are prone to failure. This book provides a multi-industry discussion of factors that contribute to failure. The authors highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure, and poorly designed safety strategies can unintentionally contribute to harm. Recommended strategies to manage risks include those utilized in patient safety work, such as multidisciplinary teamwork, process design, and systems thinking.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
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.
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
Health care has been recently been directed toward focusing on the value of teamwork in reducing risks. This publication provides extensive information about team training, including key concepts, guidelines, insights from health care workers, and strategies to improve teamwork and monitor performance.
Dekker S. Boca Raton: CRC Press/Taylor & Francis Group; 2011. ISBN: 9781439852255.
This book explores the complexity of patient safety improvement through the lens of human factors engineering and provides practical avenues for its application.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
This report describes how teams participating in The Joint Commission’s Center for Transforming Healthcare hand hygiene initiative utilized techniques to examine hand hygiene processes and identified the most common reasons why clinicians don't wash their hands.

Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.  

Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient safety movement and continues to publish groundbreaking research in the field. This essential textbook discusses the evolution of patient safety efforts, outlines current medical error reduction strategies, and emphasizes practical examples of initiatives to improve patient safety. Dr. Vincent was interviewed for AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the United Kingdom.
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.