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- Communication Improvement 1
- Culture of Safety 4
- Education and Training 1
- Error Reporting and Analysis 8
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Teamwork 1
- Health Care Executives and Administrators 7
- Health Care Providers 3
- Non-Health Care Professionals
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Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.
This report suggests that a systems approach to child social services in Great Britain would facilitate a fair and open culture and encourage learning from near misses.
Fifty-first Report of Session 2005-06. House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.
Falls Church, VA: TRICARE Management Activity, Office of the Assistant Secretary of Defense; 2006.
Freeman L. Naples Daily News. January 13, 2007.
This article reports on the progress of the Florida Patient Safety Corporation and its near miss reporting initiative.
DerGurahian J. Mod Healthc. December 7, 2009.
This article reports on accomplishments in patient safety since the To Err Is Human report was released.
Yasgur BS. Medscape Business of Medicine. December 6, 2012.
Journal Article > Study
McBride A, Holle LM, Westendorf C, et al. Am J Health Syst Pharm. 2013;70:609-617.
National drug shortages in the United States have become a serious patient safety concern. These shortages reached record levels in 2011, resulting in documented patient harm, longer stays, and increased costs. This survey of US oncology pharmacists reveals that cancer drug shortages were common during the first half of 2011 and resulted in delays and changes in chemotherapy. Use of less familiar alternatives also led to increased risk of medication errors and adverse outcomes. Near misses were reported by 16% of respondents, and 6% documented medication errors. A previous article discussed how hospitals and health care leaders might address this "patient safety crisis."
Journal Article > Commentary
Macrae C. BMJ Qual Saf. 2014;23;440-445.
This commentary examines how minor risks, when propagated and not addressed, may result in organizational disasters, as evidenced in the Francis report. The author advocates for early detection of workarounds and routine investigations into system causes of errors to reveal latent safety hazards in health care.