Gibson R, Singh JP
Washington DC: Lifeline Press; 2003

Gibson and Singh share stories of patients who have suffered devastating injuries from medical mistakes. These stories tell of lives of pain and disability, the loss of a loved one or a livelihood, and the recurring and unreimbursed costs of being disabled or injured. They recall physicians who would not visit or communicate with an error-injured patient or family member during months of corrective therapy, surgery, rehabilitation, or bereavement. The authors analogize physicians' reluctance to disclose their errors or those of colleagues to the "thin blue line" by which police conceal brutality.

Berlinger N
Baltimore, Maryland: Johns Hopkins University Press; 2005

This book draws on sources in theology, ethics, religion, and culture to create a practical and comprehensive approach to addressing the needs of patients, families, and clinicians affected by medical error. After Harm adds important human dimensions to an issue that has profound consequences for patients and health care providers.

Banja J
Sudbury, Massachusetts: Jones and Bartlett Publishers; 2005

This groundbreaking book examines common psychological reactions of health care professionals to the commission of a serious harm-causing error and the variety of obstacles that can compromise ethically sound, truthful disclosure and how error disclosure to patients and families is often compromised by the health professional’s need to preserve his or her self-esteem at the cost of honoring the patient’s right to the unvarnished truth about what has happened.

Jennings B, Baily MA, Bottrell M, Lynn J (eds). Health Care Quality Improvement: Ethical and Regulatory Issues. Garrison, NY: The Hastings Center; 2007.

This edited volume is a collection of original papers that provide in-depth discussion of how to manage QI ethically and how to manage the interface with research ethics. How does QI differ from research? What duty do physicians, nurses, and health administrators have to initiate and participate in sound QI activities? What is the responsibility of patients to cooperate with them? What practical strategies for QI management and oversight could clinicians and mangers use to ensure that QI does not harm patients?

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Tomson CRV, Berwick DM. What can the UK learn from the USA about improving the quality and safety of healthcare? Clinical Medicine. 2006 Dec;6(6):551-558.

The US health care system provides evidence that spending more on health care does not result in better care, but also offers many lessons and surprises on how the quality and safety of health care can be improved. Improving care in the UK has focused on vertically integrated, closed health care systems, but the US experience provides additional models from the work of Quality Improvement Organizations and of numerous voluntary organizations that sponsor collaborative improvement.

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Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006 Oct;118(4):1332-1340.

This article discusses the use of a NICU-focused tool for adverse event detection and describes the incidence of adverse events in NICUs identified by this tool. The authors found that adverse event rates in the NICU setting are substantially higher than previously described and the majority are preventable. They concluded that the NICU-focused trigger tool appears efficient and effective at identifying adverse events.

The Ethics of Using QI Methods to Improve Health Care Quality and Safety. The Hastings Center. July/August 2006.

This special supplement to the July/August 2006 issue of The Hastings Center report explores the ethical dimensions of efforts to make health care safer and better through continuous improvements in patient care, with special attention to the relationship between everyday QI activities and the ethical rules and regulations governing human subjects research. The report is supplemented by examples, definitions, charts, and summaries of regulations. (The report is funded by the Agency for Healthcare Research and Quality in the Department of Health and Human Services.)

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Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. Journal of the American Medical Association. 2006 Aug;296(6):696-699.

The fifth anniversary of the Institute of Medicine's To Err Is Human report on medical errors prompted widespread reflection on the progress with patient safety. Much of this reflection focused on a single question: Are patients safer now? Data from neither the entire US health care system nor individual hospitals can yield a credible answer. The inability to answer this question is doubly surprising given the increase in publicly available quality measures over the same period.

Leape LL, Rogers G, Hanna D, et al. Developing and implementing new safe practices: Voluntary adoption through statewide collaboratives. Quality and Safety in Health Care. 2006;15(4):289-295.

This article describes a statewide initiative in which a framework for (1) selecting two safe practices, (2) developing operational details of implementation, (3) enlisting hospitals to participate, and (4) facilitating implementation was developed.

Whittington J. Key issues in developing a successful hospital safety program. Agency for Heathcare Research and Quality WebM&M [serial online]. July 2006.

One of the most important interventions is for hospital leadership to get the hospital's board involved with safety and quality. Not only does the board have fiduciary responsibility for the organization, but they have responsibility for quality and safety as well. Accordingly, it is crucial for the board to explicitly make safety and quality a top priority. Boards are typically comprised of mostly nonclinical individuals, so hospital leaders and staff will need to educate them.

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