Leape LL. Reporting of adverse events. New England Journal of Medicine. 2002 Nov 14;347(20):1633-1638.

This article focuses on the role of reporting in efforts to improve safety, assess the evidence that current reporting systems improve safety, review the characteristics of successful systems, and explore options for developing new reporting systems.

Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. New England Journal of Medicine. 2002 Oct 17;347(16):1249-1255.

Description of current and proposed policies concering clinicians' work hours and fatigue.

Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE. Views of practicing physicians and the public on medical errors. New England Journal of Medicine. 2002 Dec 12;347(24):1933-1940.

Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations. To advance their agenda, national groups need to convince physicians, in particular, that the current proposals for reducing errors will be very effective.

National Patient Safety Foundation Patient Safety Literature Current Awareness Alert. Updated twice monthly on the NPSF website.

This twice-monthly publication from the National Patient Safety Foundation (NPSF) Information Center identifies articles of interest to the patient safety community. It does not provide an exhaustive list of citations, but does pinpoint items of interest from a wide array of publications.

Agency for Healthcare Research and Quality Publications Catalog. Updated periodically on AHRQ's website.

The Agency for Healthcare Research and Quality (AHRQ) funds research on key health care delivery and medical effectiveness issues. The publications in this catalog describe AHRQ programs, present research findings, and assessments of health care technologies.

Mackenzie L, Byles J, Higginbotham N. Professional perceptions about home safety: Cross-national validation of the Home Falls and Accidents Screening Tool (HOME FAST). Journal of Allied Health. 2002;31:22-28.

The Home Falls and Accidents Screening Tool (HOME FAST) was developed to measure the risk of older people falling within their home environment.

Vincent C. Understanding and responding to adverse events. New England Journal of Medicine. 2003 Mar 13;348(11):1051-1056.

In this article, the author describes a method (based on James Reason's organizational-accident model) of investigating and learning from adverse events that he and colleagues developed in Great Britain, and offers practical strategies for minimizing adverse event-related trauma.

Spath P (ed)
San Francisco, California, USA: Jossey-Bass Publishers; 2000

This book explores the complex causes of medical mistakes and offers sound advice for leaders who want to reduce the frequency of errors in health care services and mitigate the impact of those errors that do occur. The book is packed full of examples of thorough incident investigations and process improvement recommendations from leaders in the field of health care quality and risk management.

Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi T. Patient safety leadership walkrounds. Joint Commission Journal on Quality Improvement. 2003;29(1):16-26.

In the WalkRounds concept, a core group, which includes the senior executives and/or vice presidents, conducts weekly visits to different areas of the hospital. The group, joined by one or two nurses in the area and other available staff, asks specific questions about adverse events or near misses and about the factors or systems issues that led to these events.

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Massaro TA. Introducing physician order entry at a major academic medical center. Academic Medicine. 1993;68:20-25.

Article describing the barriers and obstacles encountered during an implementation of Computerized Prescriber Order Entry, in particular, the cultural challenges faced by making a significant change and how the organization handled it.