Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. Learning from mistakes: Factors that influence how students and residents learn from medical errors. Journal of General Internal Medicine. 2006 May;21(5):419-423.

This study interviewed medical students and residents in an academic medical center, and categorized the factors that influenced their learning from errors. The authors concluded that facilities could help by addressing variability in faculty response and by disseminating clear, accessible algorithms to guide behavior when errors occur. The survey also revealed the need for a teaching and learning focus on emotionally charged situations, learning from errors and near misses, and a balance between individual and systems responsibility.

Grout J. Mistake-proofing the design of health care processes. (Prepared under an IPA with Berry College). AHRQ Publication No. 07-0020. Rockville, Maryland: Agency for Healthcare Research and Quality; May 2007.

This report from the Agency for Healthcare Research and Quality provides over 150 practical real-world examples that can be applied in health care to improve patient safety. The examples — many representing simple and inexpensive ideas that can be implemented at the front lines of care — focus on design features and mistake-proofing processes to help prevent medical errors or the negative impact of errors.

Full text available. Click view report below.

Clinical Handover and Patient Safety Literature Review Report. Australian Council for Safety and Quality in Healthcare. March 2005.

The transfer of information (handover) between practitioners about patient care is an important consideration in patient safety. This report presents a comprehensive review of published and unpublished literature on clinical handover and patient safety. Clinical handovers include communication at change of shift, communication between care providers about patient care, handoffs, and information tools to assist in such communication.

Full text available. Click view report below.

Naik G. New formula: A hospital races to learn lessons of Ferrari pit stop. Wall Street Journal. November 14, 2006:A1.

This article describes various innovative techniques for improving patient handoffs (from one care unit to another), including how one British hospital aimed to improve the quality and safety of patient handovers from surgery to intensive care using the analogy of a Formula One auto racing pit stop.

Full text available. Click view article below.

"Table 1: Safe Practices, Care Settings, and Specifications." In: Safe Practices for Better Healthcare—2006 Update: A Consensus Report. Washington, DC: National Quality Forum; 2006.

In 2003, the National Quality Forum (NQF) endorsed a set of 30 safe practices to reduce the risk of harm to patients. They serve as a tool for health care providers, purchasers, and consumers to identify and encourage practices that will reduce errors and improve care. The practices were updated in 2006 and "Table 1: Safe Practices, Care Settings, and Specifications" (included here) is excerpted from the full report to provide a snapshot of the entire set of practices. The full report is available on the NQF website. Thank you to NQF and to Dr. Charles Denham for their generosity in sharing this material.

Full text available! Click view report below.

Joseph A. The Impact of Design on Infections in Healthcare Facilities. Concord, California: The Center for Health Design. July 2006; Issue Paper #1.

This research paper examines how nosocomial infections spread among hospitalized patients via environmental routes and whether the design of the hospital plays a part in preventing the incidence and spread of infections.

Joseph A. The Role of the Physical and Social Environment in Promoting Health, Safety, and Effectiveness in the Healthcare Workplace. Concord, California: The Center for Health Design. November 2006; Issue Paper #3.

This research paper examines how the physical environment, along with other factors such as culture and social support, impacts the health and safety of the care team, the care team's effectiveness in providing care and preventing medical errors, and patient and practitioner satisfaction with the experience of giving and receiving care.

Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007.

IHI Innovation Series white paper

This white paper provides comprehensive information on the development and methodology of the IHI Global Trigger Tool, with step-by-step instructions for using this easy-to-use method to accurately identify adverse events (harm) and measure the rate of adverse events over time.

Nolan TW. System changes to improve patient safety. British Medical Journal. 2000;320:771-773.

The author contends that designers of systems of care can make them safer by attending to three tasks: designing the system to prevent errors; designing procedures to make errors visible when they do occur so that they may be intercepted; and designing procedures for mitigating the adverse effects of errors when they are not detected and intercepted.

Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: Retrospective patient case note review. British Medical Journal. 2007 Jan 13;334(7584):79. Epub 2006 Dec 15.

This article evaluates the performance of routine incident reporting systems in identifying patient safety incidents in a large NHS hospital in England. The authors conclude that the routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programs.