Literature

The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’, by Robert Wachter.

Human Error: Models and Management, by James Reason. The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors.... Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work.... When an adverse event occurs, the important issue is not who blundered, but how and why the de fences failed.

A Primer on Just Culture, by David Marx. To collect productive investigative data, we must promote a culture in which employees are willing to come forward in the interests of system safety. Yet, no one can afford to offer a “blame-free” system in which any conduct can be reported with impunity — as society rightly requires that some actions warrant disciplinary or enforcement action. It is the balancing of the need to learn from our mistakes and the need to take disciplinary action that this report addresses.

Becoming a High Reliability Organization: Operational Advice for Hospital Leaders, AHRQ Publication No. 08-0022. Hospitals do most things right, much of the time. But even very infrequent failures in critical processes can have terrible consequences for a patient. Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high reliability thinking. This document is written for hospital leaders at all levels who are interested in providing patients safer and higher quality care.... it presents the thoughts, successes, and failures of hospital leaders who have used concepts of high reliability to make patient care better. It is a guidebook for leaders who want to do the same.

Priority Areas for National Action: Transforming Health Care Quality, by AHRQ. The list of priority areas identified by the committee is intended to serve as a starting point for transforming the nation’s health care system. Many of the leading causes of death are on this list. Just five of the conditions included—heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes— account for approximately 1.5 million deaths annually and represent 63 percent of total deaths in the United States... If redesigning systems of care resulted in merely a 5 percent mortality improvement in these areas alone, nearly 75,000 premature deaths could potentially be averted.

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. This compendium of practice recommendations was sponsored and authored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Partners in this work were the Association for Professionals in Infection Control and Epidemiology (APIC), the Joint Commission, and the American Hospital Association (AHA).

MedLinePlus: Patient Safety. A list of reference materials for the field.