Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. Journal of the American Medical Association. 1999;282:267-270.

To measure the effect of pharmacist participation on medical rounds in the ICU on the rate of preventable adverse drug events (ADEs) caused by ordering errors, the authors compared between phase 1 (baseline) and phase 2 (after intervention implemented), and also compared phase 2 with a control unit that did not receive the intervention. The rate of preventable ordering ADEs decreased by 66% during the intervention when pharmacists participated on physician rounds. In the control unit, the rate was essentially unchanged during the same time periods.

Kronz JD, Westra WH, Epstein JI. Mandatory second opinion surgical pathology at a large referral hospital. Cancer. 1999;86:2426-2435.

At John's Hopkins Medical Center a mandatory second opinion program was put in place and it was found that a significant portion of initial diagnoses reviewed within the study had discrepancies with the conclusions drawn.

Ko R. Adverse reactions to watch for in patients using herbal remedies. Western Journal of Medicine. 1999;171:181-186.

This review article looks at patient safety issues regarding the use of alternative medicines and offers several advisory lists for clinicians whose patients use herbal remedies.

Kahneman D, Slovic P, Tversky A
New York, NY, USA: Cambridge University Press; 1982

The classic collection of studies of how humans make judgments under (usual) conditions of uncertainty. The authors coined some of the key terms in behavioral science.

Grant S. Who's to blame for tragic error? American Journal of Nursing. 1999;99(9):9.

The author briefly recounts her institution's experience with a highly visible chemotherapy administration error.

Friedman LH, White DB. What is quality, who wants it, and why? Managed Care Quarterly. 1999;7(4):40-46.

A key concept in enhancing patient safety is the empowerment of employees to identify issues that threaten quality and then involving those employees in finding solutions to those problems. This article presents ideas about how organizational change should be approached for the successful implementation of quality management ideas.

Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic medical records: Are physicians ready? The Journal of Healthcare Management. 1999;44:440-445.

Electronic medical records are often presented as one solution for reducing medical error. This article outlines some of the barriers in successful acceptance of this mode of operation within the clinical setting.

Chassin MR, Galvin RM, et al. The urgent need to improve health care quality. Journal of the American Medical Association. 1998;280:1000-1005.

This article developed the useful framework for health care error referred to as "underuse, overuse, and misuse." It concluded that these problems exist in large and small health care organizations, and in all regions of the country.

Brennan TA, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324(6):370-376.

Description of findings that nearly 4% of patients hospitalized in acute care hospitals suffer an injury caused by treatment.

Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Academic Medicine. 1999;74(10):S138-S143.

A review article that has several purposes: 1) to describe diagnostic errors, in general; 2) to present details about two specific types of diagnostic error; and 3) to apply lessons learned to the educational process so medical students will learn how to avoid similar errors.