Rao H, Sutton R. The ergonomics of innovation. McKinsey Quarterly. 2008;4:131-141.

This article traces the history and ideas that led to IHI’s 100,000 Lives Campaign, which ran from December 2004 to June 2006. The authors are especially interested in the unique structure and mobilizing strategies that enabled so many hospitals to participate in and take advantage of this first of its kind national initiative to prevent unnecessary deaths in US hospitals.

Conway J. Could it happen here? Learning from other organizations' safety efforts. Healthcare Executive. 2008 Nov/Dec;23(6):64-67.

Another article in a series on IHI's 5 Million Lives Campaign intervention on governance leadership, the author presents a "checklist" for ongoing learning from tragic medical events. Executive leaders and boards of trustees should set a clear expectation that the lessons learned from major safety failures are translated into recommendations for changes in practice.

Classen DC, Lloyd RC, Provost L, Griffin FA, Resar R. Development and evaluation of the Institute for Healthcare Improvement Global Trigger Tool. Journal of Patient Safety. 2008 Sep;4(3):169-177.

This article reports on a study to develop and evaluate a more robust approach for the detection of adverse events in hospital patients using an enhanced Institute for Healthcare Improvement Global Trigger Tool methodology. The authors conclude that the retrospective record review approach with a two-stage review process, when used with trained reviewers, achieves high levels of agreement on the presence and severity of adverse events.

Nolan T, Martin L, Mountford J, Neumann C, Schummers D. A three-part approach to patient safety: Balanced strategy improves value, reduces costs. Healthcare Executive. 2008 Sep/Oct;23(5):70-74.

This article describes the Institute for Healthcare Improvement's three-part approach for improving the bottom-line performance in hospitals and other health care settings. Establishing a balanced strategy of initiatives and driver diagrams are explained. The balanced strategy is a tool that gives leaders a way to ensure improved patient outcomes and reduced costs.

Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Quality and Safety in Health Care. 2008 Aug;17(4):253-258.

The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery. The tool can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.

Berwick DM. Taming the technology beast. Journal of the American Medical Association. 2008 June 25;299(24):2898-2899.

This editorial comments on the report by van der Togt and colleagues on electromagnetic interference (EMI) from radiofrequency identification (RFID) technologies affecting other medical equipment in intensive care units such as infusion pumps, external pacemakers, and mechanical ventilators. The investigators found 22 of 34 EMI incidents were hazardous. Berwick points out that another important lesson of the study is that physicians and other health care decision makers should tame technology, not avoid it. [Read a related interview with Don Berwick in Materials Management in Health Care.]

Denham CR. May I have the envelope please? Journal of Patient Safety. 2008 Jun;4(2):119-123.

This article introduces the idea of applying the aviation concept of performance envelopes — testing and defining the outer limits of safety — in health care. The author proposes that there are two health care safety envelopes to be considered: 1) the boundaries of caregivers (human factors) that are defined by their skills, knowledge, and human capabilities, and often impacted by fatigue, the work environment, and distractions; and 2) the system or systems that the caregiver is operating within.

Sexton JB, Paine LA, Manfuso J, et al. A check-up for safety culture in "my patient care area”. The Joint Commission Journal on Quality and Patient Safety. Nov 2007;33(11):699-703.

The two-page Culture Check-Up Tool, which takes 30 to 60 minutes to complete as a group exercise, can help clinicians recognize and fix culture problems.

Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 2004;13(Suppl 1):i85–i90.

Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations.

Frankel A, Gardner R, Maynard L, Kelly A. Using the Communication and Teamwork Skills (CATS) Assessment to measure health care team performance. The Joint Commission Journal on Quality and Patient Safety. Sep 2007;33(9):549-558.

Patient safety administrators, educators, and researchers are striving to understand how best to monitor and improve team skills and determine what approaches to monitoring best suit their organizations. A behavior-based tool, based on principles of crisis resource management (CRM) in nonmedical industries, was developed to quantitatively assess communication and team skills of health care providers in a variety of real and simulated clinical settings.