Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008 Apr;121(4):e927-35.

This article finds that adverse drug event (ADE) rates in hospitalized children are substantially higher than previously described, and that only a small percentage (3.7 percent) of ADEs were identified using traditional voluntary reporting methods. The authors describe how a pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

Zimmerman TM, Amori G. Including patients in root cause and system failure analysis: Legal and psychological implications. Journal of Healthcare Risk Management. 2008;27(2):27-34.

The act of open disclosure of an adverse event alone may not be enough for patients or their families who are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post-event analysis allows risk management professionals to further improve their organization’s systems analysis process while empowering patients to be part of the solution. This article examines the legal and psychological considerations and provides tools for involving patients and caregivers in system failure analysis.

Shapiro E. Disclosing medical errors: Best practices from the "leading edge." Unpublished manuscript; March 2008.

Medical institutions are seeking to turn the tide of medical errors by confronting and openly admitting their mistakes, disclosing them to patients and families and throughout their institutions, investigating their causes, and using what they learn to improve processes and systems so these errors do not recur. This paper highlights the work of seven organizations to prevent and disclose medical errors, including how they’re doing it and what they’re learning in the process.

**Join the Discussion on Disclosing Medical Errors**

Conway J. Patients and families: Powerful new partners for health care and for caregivers. Healthcare Executive. 2008 Jan/Feb;23(1):60-62.

This article, the third in a series on IHI's 5 Million Lives Campaign intervention on governance leadership, focuses on key leadership strategies that can improve patient safety. The author describes engaging patients and families as partners for health care and for caregivers.

Pugh M, Reinertsen JL. Reducing harm to patients. Healthcare Executive. 2007;22(6):62, 64-65.

This article by Michael Pugh and James Reinertsen is the second in a series on key leadership strategies that can improve patient safety. Inspired by IHI’s 5 Million Lives Campaign, the authors lay out the principles and merits of dashboards to track specific and whole system quality improvement.

Yamamoto L, Marten M. Protecting patients from harm: Listen up, MRSA, the bug stops here. Nursing 2007. 2007 Dec;37(12):50-55.

This article, the last in a series highlighting clinical interventions promoted in IHI's 5 Million Lives Campaign, discusses the dangers of methicillin-resistant Staphylococcus aureus (MRSA), how to detect it, and how to keep it from spreading to vulnerable patients.

Institute for Healthcare Improvement. North Carolina Patient Safety Study. Cambridge, Massachusetts: Institute for Healthcare Improvement; February 2008. Unpublished paper.

The Institute for Healthcare Improvement has embarked on a study to measure hospital adverse event (“harm”) rates using the IHI Global Trigger Tool that will provide a foundation for similar research on a national level. The goals of the study are to: 1) develop and deploy a standardized record review methodology for measuring harm due to medical care in hospitalized patients; and 2) estimate and track the level of harm in North Carolina over time by applying this record review methodology in a representative sample of hospitals in the state.

Transforming Hospitals: Designing for Safety and Quality. AHRQ Publication No. 07-0076-1. Rockville, Maryland: Agency for Healthcare Research and Quality; September 2007.

A growing body of literature describes the link between a hospital's physical design and its key quality and safety outcomes. This report describes how evidence-based design elements can help hospitals reduce costly and avoidable incidents of patient harm such as patient falls, hospital-acquired infections, and medication errors. A companion DVD (available to order) presents the experiences of three model hospitals that use evidence-based hospital design to increase patient and staff satisfaction and safety, quality of care, and employee retention.

Griffin FA. Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections. Joint Commission Journal on Quality and Patient Safety. 2007 Dec;33(12):726-731.

This article describes five key components of care for reducing methicillin-resistant Staphylococcus aureus infections. The article is the fifth in a series describing the Institute for Healthcare Improvement's 5 Million Lives Campaign interventions.

Griffin FA. Reducing surgical complications. Joint Commission Journal on Quality and Patient Safety. 2007 Nov;33(11):660-665.

One of the 12 interventions that the Institute for Healthcare Improvement (IHI) recommends for its 5 Million Lives Campaign is to reduce surgical complications by reliably implementing all the changes in care recommended by the Surgical Care Improvement Project (SCIP). The article is the fourth in a series describing the 5 Million Lives Campaign interventions.