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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Anderson JE, Watt AJ. Int J Qual Health Care. 2020;32:196-203.
Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.

Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.
Gardner E.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Saufl NM. J Perianesth Nurs. 2009;24:114-8.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Washington State Hospital Association; WSHA
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list. 
Feldman R
In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.