Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: A practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003;18(4):201-205.

This article discusses a study to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey, initiated within 24 hours of ICU admission and completed on discharge, was implemented as part of the medication reconciliation process. Use of the survey resulted in a dramatic drop in medications errors for patients discharged from an ICU.

de Leval MR. Facing up to surgical deaths. British Medical Journal. 2004;328(7436):361-362.

The issue of surgical mortality is studied using two February 2004 British Medical Journal articles — one investigating the problems associated with statistical monitoring of surgical performance, and the other describing the impact of surgical death on health care providers. This editorial by de Leval uses both articles to develop answers to questions related to the emotional impact on health professionals from the death of a surgical patient, specifically the impact on surgeons, and investigates both long- and short-term affects on overall performance.

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Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care. Joint Commission Journal on Quality and Safety. 2004;30(1):5-14.

An increasing number of studies show that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety and reliability may be compromised. This article discusses how standardization may help to increase uniformity of practice, increase safety, and possibly reduce costs. Also described is an effort made by Luther Midlefort, Mayo Health System, to reduce variation by creating a system-wide protocol for insulin use. After six weeks, Luther Midelfort achieved a great reduction in the number of hypoglycemic events as a result of standardized practices.

Gosbee JW, Anderson T. Human factors engineering design demonstrations can enlighten your RCA team. Quality and Safety in Health Care. 2003;12:119-121.

Health care teams routinely conduct root cause analysis (RCA) of adverse events to answer three questions: What happened? Why? What can be done to prevent it in the future? A case of an RCA investigation of a retained sponge following cardiac surgery shows how human factors engineering — understanding the interactions of people and equipment — can help RCA teams focus on systems problems, instead of blaming individuals or policy violations.

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Frankel A, Gandhi TK, Bates DW. Improving patient safety across a large integrated health care delivery system. International Journal for Quality in Health Care. 2003;15 Suppl 1:i31-40.

Partners HealthCare (Boston, Massashusetts) set out to design a strategy to improve patient safety throughout their entire health care system. With the organization of designated patient safety personnel and leadership, there was strong agreement that the key areas of focus include culture change, process change, and process measurement. The article discusses some of the tools and processes the system implemented.

Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. Working hours of hospital staff nurses and patient safety. Health Affairs. 2004;23(4): 202-212.

This study discusses the prevalence of extended work periods in nursing and its effects on patient safety. The study findings suggest that the risk of error increased significantly when nurses worked more than 12 hours, worked overtime, or worked more than 40 hours per week.

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

The authors claim that going forward in the next century, medicine's greatest breakthroughs will not be in new treatments but in improving how current care is delivered. To that end, the authors offer a mechanism to evaluate the care that is currently provided.

Kohn LT, Corrigan JM, Donaldson MS, eds. (Committee on Quality of Health Care in America, Institute of Medicine)
Washington, DC, USA: National Academies Press; 1999

This report lays out a comprehensive strategy to reduce medical errors for government, industry, consumers, and health care providers, and it calls on the United States Congress to create a national patient safety center to develop the new tools and systems needed to address persistent problems. Each chapter of the report contains a reference list, allowing the reader to select additional material in specific areas of interest.

Robeznieks A. Simulated hospital center would be first of its kind. amednews.com:The Newspaper for America's Physicians [serial online]. June 28, 2004. Available from: American Medical Association.

Stephen D. Small, MD, the director of the University of Chicago's Developing Center for Patient Safety, has launched a plan to create a full-scale hospital simulation center for training medical professionals in the Midwest. The hope is to design an environment that will allow the medical workforce to understand the importance of a well-integrated system of care.

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Baker GR, Norton PG, Flintoft V, Blais R, Brown A, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal. 25 May 2004;170(11):1678-1686.

This is the first study seeking to quantify the incidence of adverse events (AEs) experienced by hospital patients in Canada and points to an overall incidence rate of 7.5 percent. Of these, more than a third are potentially preventable.