Wiener EL, Kanki BG, Helmreich RL
San Diego, California, USA: Harcourt Brace; 1993

This book describes the technique of Cockpit Resource Management, also known as Crew Resource Management, and how it is used by pilots to improve safety.  The system, based on communication techniques, can also be adapted to hospital settings.

Hirsh J. Evidence for the needs of out-of-hospital thrombosis prophylaxis. Chest. 1998 Aug;114(2 Suppl Evidence):113S-114S.

A conference of experts was convened by the American College of Chest Physicians to discuss the issues surrounding thrombosis prophylaxis at time of discharge. This introduction describes the conference proceedings and provides a context for the series of articles that were written about this issue.

Leape LL. Errors are not diseases: They are symptoms of diseases. Laryngoscope. 2004;114(8):1320-1321.

In this editorial Lucian L. Leape, MD, provides a commentary on a study on developing a preliminary classification system for errors in otolaryngology.  He uses the disease/symptom of disease relationship to explain that errors are merely the symptoms of the deeper broken system of care.

Shah RK, Kentala E, Healy GB, Roberson DW. Classification and consequences of errors in otolaryngology. Laryngoscope. 2004;114(8):1322-1335.

This study was designed to develop a preliminary classification system for errors in otolaryngology. The findings suggest that errors in this specialty cause “appreciable morbidity and mortality” and make a strong case for developing error classification systems which are specifically designed for individual realms of specialty practice.

See related editorial: Leape LL. Errors are not diseases: They are symptoms of diseases.

Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. New England Journal of Medicine. 1999;341(24):1789-1794.

The authors of this study show how perioperative beta-blockade reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.

Miller MR, Zhan C. Pediatric patient safety in hospitals: A national picture in 2000. Pediatrics. June 2004;6(113):1741-1746.

Miller and Zhan set out to identify potential patient safety events for hospitalized children, examine associated factors, and explore impacts of safety events. They learned that patient safety problems for hospitalized children occur frequently and with substantial impacts to the US health care industry.

Leonard M, Frankel A, Simmonds T; with Vega K
Health Administration Press; 2004

Every health care organization must address the issue of medical errors or face the negative response of the public, the media, and regulatory bodies. This book will provide you with a comprehensive blueprint for building and supporting a culture of patient safety.

Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine. 2003;348(3):229-235.

This article describes a study to determine the severity of risk associated with medical errors from foreign bodies in surgical patients. The study included 54 patients with a total of 61 retained foriegn bodies (69% of which were sponges, while the remaining 31% were instruments). The majority of cases resulted in reoperation. The investigation concluded that in an emergency concerning a patient with a high body mass index, the risk of retention of foriegn bodies increases.

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Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet. 2004;363(9414):1061-1067.

Evidence suggests that the greatest opportunity to improve outcomes for patients will probably come not from discovering new treatments but from learning how to deliver existing effective therapies. This article presents a practical method for caregivers to learn from routine practice using evaluation of performance and frequent feedback.

Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, Gurwitz JH. Health plan members' views about disclosure of medical errors. Annals of Internal Medicine. 2004;140(6):409-418.

This article discusses a survey administered in a New England-based managed care plan to examine how patients reacted in cases where they were given either full or non-disclosure about an error that occurred during their visits with a physician. The study concluded that more favorable outcomes (e.g., reduced likelihood of changing physicians, increased patient satisfaction and trust) were likely when patients were fully disclosed about any medical errors. Almost all respondents (98.8%) wanted to be told of errors.

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