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Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Study
Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.
Journal Article > Review
Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.
Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A past AHRQ WebM&M interview with Dr. Pat Croskerry explored the role of cognition in medical error.