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- Review 1
- Study 2
- Slideset 2
- Legislation/Regulation 20
- Special or Theme Issue 7
- Glossary 1
- Toolkit 20
- Web Resource 249
- Award 2
- Bibliography 2
- Grant 1
- Meeting/Conference 21
- Press Release/Announcement 2
Communication between Providers
- Sbar 2
- Communication between Providers 54
- Culture of Safety 168
Education and Training
- Students 4
Error Reporting and Analysis
- Never Events 21
- Error Reporting 143
Human Factors Engineering
- Checklists 13
Legal and Policy Approaches
- Regulation 23
- Logistical Approaches 24
- Policies and Operations 10
Quality Improvement Strategies
- Benchmarking 40
- Research Directions 9
- Specialization of Care 18
- Teamwork 49
- Clinical Information Systems 46
- Transparency and Accountability 16
- Device-related Complications 18
- Diagnostic Errors 34
- Discontinuities, Gaps, and Hand-Off Problems 54
- Drug shortages 7
- Failure to rescue 1
- Fatigue and Sleep Deprivation 6
- Identification Errors 16
- Inpatient suicide 1
- Interruptions and distractions 2
- Medical Complications 86
- Medication Errors/Preventable Adverse Drug Events 65
- Nonsurgical Procedural Complications 13
- Overtreatment 5
- Psychological and Social Complications 43
- Second victims 2
- Surgical Complications 61
- Transfusion Complications 3
- Ambulatory Care 98
- General Hospitals 56
- Long-Term Care 21
- Outpatient Surgery 12
- Patient Transport 1
- Psychiatric Facilities 5
- Allied Health Services 2
- Geriatrics 14
- Pediatrics 18
- Primary Care 29
- Internal Medicine 188
- Nursing 26
- Pharmacy 39
- Family Members and Caregivers 20
- Health Care Executives and Administrators 686
Health Care Providers
- Nurses 29
- Pharmacists 17
- Physicians 65
Non-Health Care Professionals
- Educators 45
- Engineers 20
- Media 9
- Policy Makers 172
- Patients 105
- Africa 2
- Asia 1
- Australia and New Zealand 12
- United Kingdom 146
- Canada 29
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 147
- United States Federal Government 191
Search results for "Book/Report"
The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994.
Sinclar M. Provincial Court of Manitoba, CA.
A 3-year review investigating a series of deaths from a pediatric cardiac unit revealed flaws in the recruitment process, quality assurance mechanisms, treatment of nurses, staffing, and lines of authority. The report offers recommendations for necessary quality improvements.
Scheffler A, Zipperer LA, eds. Chicago, IL: National Patient Safety Foundation; 1999.
The proceedings from the 1998 Annenberg meeting hosted in Rancho Mirage, California.
Juran JM, Blanton GA. New York, NY: McGraw-Hill Companies; 1999.
This reference on quality engineering and management practices provides a wealth of background and scholarship on the elements of quality improvement, or how an organization plans and achieves quality. Its five primary sections focus on managing quality, how quality functions throughout the product development continuum, industry-oriented achievements in quality, geographical quality management examples, and statistical tools as aids to articulate quality improvement. Health care is one of the industries spotlighted.
Perrow C. Princeton, NJ: Princeton University Press; 1999. ISBN: 0691004129.
Though less often cited than high-reliability theory in the health care literature, normal accidents theory is equally prominent in the study of complex organizations. A more pessimistic view, normal accidents theory suggests that, in some settings, a major accident becomes almost inevitable. Perrow identifies "complexity" and "tight coupling" as the two factors that create an environment in which a major accident becomes more rather than less probable over time, regardless of steps taken to increase safety. The degree of complexity Perrow has in mind occurs when no single operator can immediately foresee the consequences of a given action in the system. Tight coupling occurs when processes are intrinsically time-dependent: once a process has been set in motion, it must be completed within a certain period of time. Many health care organizations would meet Perrow's definition of complexity, but only hospitals would be regarded as exhibiting tight coupling. Nuclear power provides the archetypal complex, tightly coupled system, and an analysis of the near disaster at Three Mile Island provides the centerpiece of the book. Even if one does not share Perrow's conclusion about the potential for catastrophe as an intrinsic property of certain complex systems, the case studies offer many fascinating insights into the possible failure modes for complex organizations, including hospitals.
van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.
This report provides a detailed review of risk management in complex and high-risk organizations. The author focuses on the analysis and categorization of safety-related incidents and their organizational causes.
Casey SM. Santa Barbara, CA: Aegean Publishing Company; 1998. ISBN 13: 9780963617880.
This book introduces important human factors issues using a series of real cases and incidents from health care and a variety of other industries. The title refers to the disastrous death of a patient due to a design flaw in the radiotherapy accelerator, Therac-25. A plausible but unanticipated series of keystrokes by the operator resulted in the delivery of more than 100 times the intended dose of radiation. Other chapters discuss events as diverse as the Union Carbide disaster in Bhopal, India, an incorrect stock trade that nearly caused a market collapse, a variety of military and industrial examples, as well other cases from health care. The book provides numerous real-world examples of misadventures in human–system interactions.
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1998.
A report from a workshop, this document is a well-written look at the differences between "first stories" and "second stories" describing major errors. First stories are the easy one-person or one-cause accounts and reactions to critical incidents. "So-and-so forgot to check the patient's allergy history." Or "How could they have ignored the alarm and so many other red flags?" Even now, with some penetration of the concepts of systems thinking, it is still easy to fall back on the familiar and easy explanation of human error, missing key opportunities to fix underlying problems with processes of care or the way care is organized. Identifying such problems, however, requires the far richer "second stories" about such critical incidents, and these stories do not emerge without hard work. The authors have done this hard work for many publicized medical errors, drawing on follow-up newspaper articles and other investigative documents, often in far more obscure places than headlining first stories. Even readers familiar with root cause analysis will likely find value in many of the case studies. And, for those not familiar with such accident investigation techniques, the report provides a very readable introduction to their importance and a resource for further references.
Helmreich RL, Merritt AC. Aldershot, Hampshire, England: Ashgate; 1998.
This book examines the influence of professional, national, and organizational cultures on shaping individual attitudes, values, and team interactions in both aviation and medicine. The research comes largely from research on culture and teamwork in aviation, but the intended audience clearly includes those interested in error reduction in health care, and many of the cases and vignettes discussed come from medicine. In recent years, the importance of teamwork and organizational culture has gained increasing attention within health care, especially within patient safety. This book provides an introduction to these topics and also contains ample material that will likely be new for those already familiar with the area.
Leape LL, Kabcenell A, Berwick DM, Roessner J. Boston, MA: Institute for Healthcare Improvement; 1998.
This application-oriented book provides the results of the Institute for Healthcare Improvement (IHI) Breakthrough Series program focusing on decreasing adverse drug events in health care facilities. More than 40 organizations share their collective learning experience, from planning for improvement, testing ideas, studying what they learned, and implementing change. The book’s numerous case studies, descriptions of step-wise improvement processes, and strategies for breaking down organizational barriers help illustrate the experience and methods that led to the group’s success. The book will be valuable to individuals and institutions attacking the problem of medication errors or seeking insight into collaborative learning models.
Klein G. Cambridge, MA: MIT Press; 1998.
Sharpe VA, Faden AI. New York, NY: Cambridge University Press; 1998.
An academic exploration into the history of patient harm, this book explores the ethics that drive decision making and management of the professionals involved. Within that context, the changes in the patient-physician relationships over time are reviewed. The problems and dangers inherent in medical progress, from adverse drug reactions to unnecessary surgery, are discussed, and causative factors from both the clinical and administrative sides of medicine are presented as contributors to the situation. The complexity of care relationships is viewed as playing a role in how appropriate treatment for patients is determined. The authors believe that the more players involved with the decision-making process, the more opportunities for dysfunction arise. They close by presenting ideas for minimizing iatrogenic illness, with the caveat that it can never be removed completely due to the humanness of the process of medicine.
Davenport TH, Prusak L. Boston, MA: Harvard Business School Press; 1998. ISBN: 0875846556.
Morell RC, Eichhorn JH, eds. New York, NY: Churchill Livingstone; 1997. ISBN: 9780443076824.
Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the convergence that resulted in successful change in that specialty in the 1970s. He and Morell are well suited to be at the helm of the first anesthesia textbook on patient safety. The book opens with a recap on anesthesia's historic involvement in achieving and sustaining safety improvements. In addition, authors provide clinical guidance on topics such as positioning and airway algorithms and the use of simulators as training environments. A variety of solutions are provided to support continued success in this highly technical area of medicine.
Millenson ML. Chicago, IL: University of Chicago Press; 1997.
Millenson, a Pulitzer-nominated former health care writer, discusses the health care quality movement and the increasingly important role of information technology in both measuring and promoting quality. He covers a broad range of topics in a somewhat journalistic tone, from quality assessment to evidence-based medicine, from accountability to pay-for-performance. Although the book is nearly a decade old, it remains important for having laid out a vision for the use of information and computerization in assessing and promoting quality. Although the book includes sections on patient safety, its strengths are those on quality assessment and improvement.
Reason JT. Aldershot, Hampshire, England: Ashgate; 1997.
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest and illustrates many of the key concepts that ultimately formed the core of the patient safety movement. Much of Lucian Leape's work in Error in Medicine involved translating Reason's concepts into health care applications. In this seminal book, readers are introduced to the now-famous "Swiss cheese model" of errors in high-risk enterprises, the difference between active and latent errors, the difference between "slips" and "mistakes," the importance of a safety culture, the role of regulation, training and incentives, and much more. This book provides a good introduction to safety and systems theory.
Vaughan D. Chicago, IL: University of Chicago Press; 1997.
A model of root cause analysis on a system-wide scale, Vaughan's analysis of the Challenger crash looks beyond the widely held belief that pressure from NASA management to meet a launch schedule contributed to the decision to bypass multiple internal warnings. Vaughan identifies two general causes other than pressures related to the timeline: a dispersion of knowledge to silos within the organization, exacerbated by a tendency toward secrecy within silos, and a culture in which unexpected or unwanted test results were minimized, explained away, or out-and-out dismissed. Vaughan refers to this second tendency as the ''normalization of deviance,'' a phenomenon that shares many features with the ''status quo bias'' discussed in cognitive psychology. In both cases, potential warnings alerting individuals or groups to the possibility of serious error are cast as consistent with a prevailing belief or strategy, rather than interpreted as grounds for casting it aside. Those who have worked in a health care organization in which a prominent, adverse event has occurred will find the discussion of the aftermath particularly sobering.
Turner BA, Pidgeon NF. 2nd ed. Boston, MA: Butterworth-Heinemann; 1997. ISBN: 0750620870.
For those interested in potential lessons drawn from analyses of major accidents in other industries, this book, originally published in 1978, still provides a number of interesting case studies.
Tenner E. New York, NY: A.A. Knopf; 1996.
Tenner's discussions of medical and nonmedical examples provide an engaging introduction to the many ways in which new technologies can have unintended consequences. Side effects of any technology are well known and well studied. What interests Tenner, however, are ''revenge effects,'' which he defines as the exact opposite of the intended effects of a new technology. For instance, the widespread availability of computers in offices and homes was heralded as ushering in a new, paperless world. Instead, paper use sky-rocketed. From a safety perspective, numerous examples exist in which making something safer simply encouraged more reckless behavior. Health care examples often involve a safer version of a drug or procedure, which then becomes overused. At the population level, then, adverse events do not decrease and may even increase. For instance, laparoscopic cholecystectomy is a much less morbid procedure than open cholecystectomy. It is this feature of the laparoscopic procedure that resulted in a significant increase in the number of patients referred for removal of their gallbladder, to the point that morbidity and mortality at the population level did not improve as a result of this major advance in surgical technology.
The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.
Robins NS. New York, NY: Delacorte Press; 1995. ISBN 0385308094.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
Weick KE. Thousand Oaks, CA: Sage Publications; 1995.
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen in his story Escape Fire, which illustrates the disasters that befall teams when "sensemaking" is absent or disappears in a crisis. Weick's thinking encompasses the notion that both individuals and teams often overlook important problems because they put on cognitive blinders based on their biases and expectations and that individuals or teams working in complex enterprises often err because they lose the ability to make rational decisions in the face of crises. All of this is useful and intuitively logical, although one finishes Weick's book not entirely sure how to improve sensemaking in a clinical context.