Espinosa J, Nolan T. Reducing errors made by emergency physicians in interpreting radiographs: Longitudinal study. British Medical Journal. Mar 2000;320:737-740.

Article which reflects a longitudinal study on reducing errors by physicians in the emergency department when reading radiographs.  The results show that with proper improvement measures, errors can be reduced dramatically. 

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Maund T, Espinosa JA, Kosnik LK, Scharf J. Video-storytelling: A step-by-step guide. Joint Commission Journal on Quality and Safety. 2003 Mar;29(3):152-155.

This article presents step-by-step instructions for using video-storytelling to address safety or performance improvement issues in the workplace. The tool was developed by Overlook Hospital/Atlantic Health System (Summit, New Jersey, USA).

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Bates DW, O’Neil AC, Boyle D, Teich J, Chertow G, Komaroff A, et al. Potential identifiability and preventability of adverse events using information systems. Journal of the American Medical Informatics Association. 1994;1(23):404-411.

Description of the use of a computerized screening system that identifies potential adverse drug events by use of a logic system based on laboratory data and orders. Shows what can be done if all clinical and laboratory information is online.

Leape LL, Kabcenell A, Berwick DM, Roessner J
Boston, Massachusetts, USA: Institute for Healthcare Improvement; 1998

**NOTE: This Breakthrough Series Guide was published in 1998 and has NOT been updated. Please be advised that much of the clinical content may be out of date.**        Institute for Healthcare Improvement (IHI) Breakthrough Series Guides are based on the real-life experiences of health care organizations that have made dramatic changes while participating in IHI Breakthrough Series Collaboratives. Each Guide contains a synopsis of a Collaborative’s goals and results, the model for accelerating improvement, change concepts that Collaborative participants used successfully, additional resources, key contacts, and a bibliography. This Guide is based on the 1996–97 Collaborative on Reducing Adverse Drug Events.

Maund T, Espinosa J, Kosnik L, Scharf J. Tool Tutorial Video-Storytelling: A Step-by-Step Guide. Joint Commission Journal on Quality and Safety. 2003; 29:3:152-155.

This article gives you a step-by-step guide on how to turn a story into a storytelling video. It is specifically geared towards safety or performance improvement initiatives.

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The report by the Columbia Accident Investigation Board on the causes of the space shuttle tragedy offers lessons that extend far beyond NASA. The health care industry, for one, has much to learn from it about patient safety.

Sutcliffe KE, Weick KM
San Francisco, California, USA: Jossey-Bass; 2001

Describes how high reliability organizations (HRO's) perform efficiently in high stress situations.  The authors demonstrate how to respond to tough challenges using tools they describe and explain.

Institute of Medicine Committee on Data Standards for Patient Safety
Washington, DC, USA: National Academies Press; 2003

In November 2003, the Institute of Medicine released this report describing a detailed plan to facilitate the development of data standards for the collection, coding, and classification of patient safety information. Among other recommendations, the report suggests that computerized information systems should be implemented nationally.

Sharpe V. Promoting Patient Safety: An Ethical Basis for Policy Deliberation. The Hastings Center. Special Supplement 33(5);2003:S1-S20.

This report from The Hastings Center focuses on the integration of ethical concerns while developing new policies to improve patient safety. The report was created from a research project that began in reaction to the IOM report, To Err Is Human.

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Anyone involved in quality improvement efforts knows that scientific principles are at the center of this work. But even the most evangelical quality engineer will caution that this only part of the solution. As Donald Berwick, MD, MPP, puts it, "Measurement is important, but it’s the stories behind the numbers that are the most enduring wellspring for change."