References and Recommended Reading

1. Recommended Reading
   1. General Reading on Patient Safety
   2. Readings Related to High Reliability Organizations
   3. Readings Related to Managing Safety Risks
   4. Readings Related to Optimizing Human and Environmental Factors
   5. Readings Related to Recognizing, Responding to and Disclosing Adverse Events
2. References
   1. Contributing to the Culture of Patient Safety
   2. Work in Teams for Patient Safety
   3. Communicate Effectively for Patient Safety
   4. Manage Safety Risks
   5. Optimize Human and Environmental Factors
   6. Recognize Respond to and Disclose Adverse Events

Recommended Reading

General Reading on Patient Safety

1.  Leape LL. Safe health care: are we up to it? BMJ2000;320:725-726
2. Leape LL. A series on patient safety. Editorial NEJM 2002;347:16:1272-4
3. Reinertsen JL Let’s talk about error. BMJ2000;320:730
4. Brennan TA, Leape LL,Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. NEJM 1991; 324(6):370-376
5. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients. N Engl.J Med 1991; 324(6): 377-84
6. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care.2000; 38(3):261-271
7. Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ 1998; 316: 1154-57
8. Kohn LT, Corrigan JM, Donaldson MS, eds. 1999. To Err is Human: Building a Safer Health Care System. National Academy Press, Washington, DC.
9. Baker GR, Norton PG, Flintoft V et al. The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada CMAJ 2004; 170 (11): 1678-86
10.  Weingart SN, McL Wilson R, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ 2000; 320: 774-777
11. Miller M, Elixhauser A, Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics. 2003; 111:6:1358-1366
12. Miller.M and Zhan C. Pediatric patient safety in hospitals: a national picture in 2000. Pediatrics 2004; 113:6:1741-1746
13. Woods D, Thomas E, Holl J, Altman S, Brennan T. Adverse events and preventable adverse events in children. Pediatrics 2005; 115(1): 155-160.
14. McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Preventable adverse events in infants hospitalized with bronchiolitis. Pediatrics 2005; 116(3): 603-608.
15. Proctor ML, Pastore J, Gerstle JT, Langer JC. Incidence of medical error and adverse outcomes on a pediatric general surgery service. J Ped Surg 2003;38(9):1261-1265

Readings Related to High Reliability Organizations

1. Weick: Managing the Unexpected: High Reliability Organizations - Available from Amazon Books - $19.97
2. Reason J. Human error: models and management. BMJ 2000;320: 768-770
3. Accreditation Canada Patient Safety ROPs
4. IHI White Papers - Supports the characteristics and capacities of organizations

Readings Related to Managing Safety Risks

1. Human error: models and management. James Reason. BMJ 2000
2. Managing the Unexpected. Weick and Sutcliffe. 2007. Wiley Books. (extra)
3. Leonard MS et al. Risk Reduction for Adverse Drug Events Through Sequential Implementation of Patient Safety Initiatives in a Children’s Hospital. Pediatrics 2006.

Readings Related to Optimizing Human and Environmental Factors

1. Lockley et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1829-1837.
2. Landrigan et al. Effect of reducint interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1838-1848.
3. Landrigan et al. Interns' compliance with accreditation council for medical education work-hours limits. JAMA 2006Sept6;296(9):1063-1070.
4. Lockely et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual patient safety 2007 Nov;33(11 Suppl):7-18.
5. Landrigan et al. Effective implementaiton of work-hour limits and systemic improvements. Jt Comm J Qual patient safety 2007 Nov;33(11 Suppl):19-29.
6. Fahrenkopf AM et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008 Mar1;336(7642):488-491.
7. Janney M, Landrigan C. Improving nurse working conditions: towards safer models of hospital care. J Hosp Med. 2008 May:3(3):181-183.
8. Landrigan et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 1008Aug;122(2):250-258.
9. Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA. 2008 Sep 10;300(10):1197-1199
10. Reason’s article Qual Saf Health care 1995; 4:80-89
11. Vincent et al BMJ 1998;316:1154-57
12. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80.
13. Croskerry PG. The cognitive imperative: thinking about how we think. Acad Emerg Med 2000;7(11):1223–31.
14.  Norman DA. The design of everyday things. New York: Basic Books; 1988.
15. Vicente K. The human factor: revolutionizing the way people live with technology. Toronto: Knopf; 2003  This web site has a downloadable power point deck and support material
16.  Reason J. Beyond the organizational accident: the need for “error wisdom” on the frontline. Qual Saf Health Care 2004; 13:ii28-ii33

 Reason presents a case of vincristine given intrathecally to an 18 year old patient who died 3 weeks later. He analyzes all the underlying issues but makes a plea for training frontline nurses and doctors in error preparedness in order to instill ‘informed vigilance and intelligent wariness in those at the sharp end’.

This includes:

• Accept that errors can and will occur
• Assess the local bad stuff before embarking on a task
• Have contingencies ready to deal with anticipated problems
• Be prepared to seek more qualified assistance
• Do not let professional courtesy get in the way of checking your colleagues’ knowledge and experience, especially when they are strangers
• Appreciate that the path to adverse events is paved with false assumptions

Readings Related to Recognizing, Responding to and Disclosing Adverse Events

1. CMPA Disclosure Toolkit
2. CPSI Canadian Disclosure Guidelines - includes PDF version and list of Provincial Speakers on Disclosure
3. Health Quality Council of Alberta. Disclosure of Harm to Patients and Families - Provincial Framework
4. College of Physicians and Surgeons of Ontario. Disclosure of Harm Policy
5. Provincial Disclosure Legislation and Apology Acts - official versions must be obtained from Statutory Publication
6. DVD - Removing Insult From Injury; Disclosing Adverse Events - available for $99.95 US + shipping

References

Contributing to the Culture of Patient Safety

1. PizziLT, GoldfarbNI, Nash DB. Promoting a culture of patient safety. In Shojania KG, Duncan BW, McDonald KM editors. Making healthcare safer: a critical analysis of patient safety practices. Evidence Report/Technology Asssessment No 43. Prepared by the University of California at San Francisco-Stanford Evidence-based Practice Centre. AHRQ Publication No. 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001. p 447-57.
2. Reason J. Human error. Cambridge (UK): Cambridge University Press 1990
3. Reason J. Managing the risks of organizational accidents. Aldershot (UK): Ashgate; 1997
4. Vincent C. Patient safety. Edinburgh: Elsevier Churchill Livingstone; 2006
5. Weick KE, Sutcliffe KM. Managing the unexpected. San Francisco: Jossey-Bass; 2001

Work in Teams for Patient Safety

1. Canadian Medical Protective Association. Collaborative care: a medical liability perspective. Ottawa: The Association; 2007. Available from: www.cmpa-acpm.ca (accessed 2008 Jan 24).
2. Clements D, Dault M, Priest A. Eff ective teamwork in healthcare: research and reality. Healthcare Papers 2007;7(Spec no):26–34.
3. Fay D, Borrill C, Amir Z, Haward R, West MA. Getting the most out of multidisciplinary teams: a multisample study of team innovation in health care. J Occup Organ Psychol 2006;79(4):553–67.
4. Gilbert JH. Interprofessional learning and higher education structural barriers. J Interprof Care 2005;19(Supp. 1):87–106.
5. Hunt EA, Shilkofski NA, Stavroudis TA, Nelson KL. Simulation: translation to improved team performance. Anesthesiol Clin 2007;25(2):301–19.
6.  Leonard M, Graham S, Bonacum D. The human factor: the critical importance of eff ective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13(Suppl 1):i85–i90.
7.  Oandasan I. Teamwork and healthy workplaces: strengthening the links for deliberation and action through research and policy. Healthcare Papers 2007;7(Spec no):98–103.
8.  West MA, Borrill CS, Dawson JF, Brodbeck F, Shapiro DA, Haward R, et al. Leadership clarity and team innovation in health care. Leadership Q 2003;14:393–410.

Communicate Effectively for Patient Safety

1. Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA 1999;282(24):2313–20.
2. Cooke L, Dojeiji S, Kurtz S, Laidlaw T, Sherbino J, Frank J. The CanMEDS train-the-trainer communicator faculty development program. Ottawa:The Royal college of Physicians and Surgeons of Canada; 2007.
3. Egan G. Essentials of skilled helping: managing problems, developing opportunities. Chicago: Thomson/Wadsworth; 2006.
4. Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. Oxford: Radcliffe; 2005.
5. Patterson K, Grenny J, McMillan R, Switzler A. Crucial conversations: Tools for talking when stakes are high. New York: McGraw-Hill; 2002.
6. Patterson K, Grenny J, McMillan R, Switzler A. Crucial confrontations: Tools for resolving broken promises, violated expectations and bad behavior. New York, NY: McGraw-Hill; 2005.

Manage Safety Risks

1. Connor M, Ponte PR, Conway J. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin N Am 2002;14(4):359–67.
2. Dekker SWA. Ten questions about human error: a new view of human factors and system safety. Boca Raton (FL): CRC Press; 2004.
3. Flin R, Glavin R, Patey R. Anaesthetists’ Non-Technical Skills (ANTS) System Handbook v1.0. Aberdeen: University of Aberdeen. Available from: www.abdn.ac.uk/iprc/ANTS (accessed 2008 Jan 24).
4. Gaba DM. Anaesthesiology as a model for patient safety in health care. BMJ 2000;320(7237):785–8.
5. Hollnagel E. Barriers and accident prevention. Aldershot (UK): Ashgate; 2004.
6. Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: What to try and what to avoid. Med Clin North Am 2008;92(2):275–293, vii–viii.
7. Senge PM. The fi fth discipline: the art and practice of the learning organization. New York: Doubleday;1990.
8. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Rockville (MD): Agency for Healthcare Research and Quality; 2001. Available from: www.ahrq.gov/clinic/ptsafety/pdf/front.pdf (accessed 2008 Jan 24).
9. Wong J, Beglaryan H. Strategies for hospitals to improve patient safety: a review of the research. Toronto:The Change Foundation; 2004. Available from: www.caphc.org/documents_programs/patient_safety/patient_safety_2004.pdf (accessed 2008 Jan 24).

10. Weick K, Sutcliff e K. Managing the unexpected. San Francisco: Jossey-Bass; 2001.

Optimize Human and Environmental Factors

1. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80.
2. Croskerry PG. The cognitive imperative: thinking about how we think. Acad Emerg Med 2000;7(11):1223–31.
3. Norman DA. The design of everyday things. New York: Basic Books; 1988.
4. Vicente K. The human factor: revolutionizing the way people live with technology. Toronto: Knopf; 2003.

Recognize Respond to and Disclose Adverse Events

1. American Society for Healthcare Risk Management. Disclosure: what works now and what can work even better (one of three). Journal of Healthcare Risk Management; 24(1):19-26.
2. Canadian Medical Protective Association. Communicating with your patient about harm: disclosure of adverse events. Ottawa: CMPA, 2008. Available from: www.cmpa-acpm.ca (accessed 17 July 2008).
3. Disclosure Working Group. Canadian disclosure guidelines. Edmonton: Canadian Patient Safety Institute; 2008.
4. Full Disclosure Working Group. When things go wrong: responding to adverse events. a consensus statement of the Harvard Hospitals. Boston: Massachusetts Coalition for the Prevention of Medical Errors, 2006.
5. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001–7.
6. Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med 2007;28;356(26):2713–19.
7. Health Quality Council of Alberta. Disclosure of harm to patients and families: provincial framework.HQCA; 2006. Available at: www.hqca.ca/index.php?id=58
8. Lazare A. Apology in medical practice: an emerging clinical skill. JAMA 2006;296(11):1401–4.
9. Leape, L.L. Full disclosure and apology—an idea whose time has come. Physician Executive. 2006 March;32(2):16-18.
10. Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med 2003;18(1):61–7.
11. White J. Adverse event reporting and learning systems: a review of the relevant literature. Edmonton: Canadian Patient Safety Institute; 2007.
12. World Alliance for Patient Safety. Forward Programme 2008-2009. Available at: www.who.int/patientsafety/information_centre/reports/Alliance_Forward_Programme_2008.pdf