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- Communication Improvement
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Quality Improvement Strategies 2
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 2
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 2
- Medical Complications 2
- Medication Safety 2
- Surgical Complications 2
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ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Journal Article > Commentary
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.
This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
O'Reilly KB. American Medical News. June 14, 2010.
This news piece discusses how the health care industry can apply aviation safety methodologies to guide improvement.
Journal Article > Study
de Korne DF, van Wijngaarden JDH, Hiddema UF, Bleeker FG, Pronovost PJ, Klazinga NS. Jt Comm J Qual Patient Saf. 2010;36:339-347.
This study describes a near 20-year experience with diffusion of aviation-based innovation into a hospital setting, including programs focused on teamwork training and surgical time outs. The authors provide an analysis framework for the diffusion efforts and provide recommendations for institutions seeking to replicate their success.