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Bunting RF Jr, Schukman J, Wong WB. Washington, DC: Atlantic Information Services, Inc.; 2009. ISBN: 1933801557.
This biannually updated publication and companion CD provide detailed health care risk management strategies and tools to reduce adverse events.
Journal Article > Study
The relationship between organizational leadership for safety and learning from patient safety events.
Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.
The role of organizational leadership in ensuring patient safety has been recognized by accrediting organizations such as The Joint Commission, who issued a sentinel event alert calling attention to the issue and have also developed leadership standards. This Canadian study sought to quantify the relationship between leadership and organizational learning from safety events, and found that hospitals with stronger safety leadership structures demonstrated a greater capacity to learn from errors and near misses. This relationship was particularly true for smaller hospitals. An AHRQ WebM&M perspective discusses how one hospital responded to a never event.
Youngberg BJ, ed. Sudbury, MA: Jones Bartlett; 2011. ISBN: 9780763774059.
This textbook discusses claims management, risk financing, and proactive risk reduction within the context of patient safety improvement.
Journal Article > Study
To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.
Fareed N, Mick SS. Health Care Manage Rev. 2011;36:288-298.
The National Quality Forum first defined a set of never events to highlight significant errors that should never occur. This list gained traction in 2007 when the Centers for Medicare & Medicaid Services announced that it wouldn't pay for additional costs associated with these errors. This article provides a theoretical framework to understand which hospitals may engage in safety solutions, and whether these solutions are created within their structures or by using outside suppliers. Their findings suggest that hospitals with certain characteristics (e.g., larger, teaching, safety net, competitive) are more likely to engage in innovations, and that those reacting positively will internalize their innovations rather than approach the market. An accompanying editorial challenges the commentary's assertions, suggesting their views may be too narrow or provide an incomplete perspective of strategic behavior and decision-making around patient safety.
Special or Theme Issue
Ganguli I, ed. Virtual Mentor. 2011;13:587-678.
With a focus on advancing education for physicians and trainees, articles in this special issue explore major patient safety themes such as errors and accountability, disclosure and coping, hand-offs, never events, patient safety organizations, and systems failures in medical practice.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.