Hader R. Best-practice protocols: Every second counts. Nursing Management. Jun 2005;36(6):28-33.

This article, the first in a series, gives an overview of the six interventions recommended by the Institute for Healthcare Improvement as part of its 100,000 Lives Campaign to reduce hospital deaths, as well as other initiatives to improve patient safety.

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Bok S
New York, New York, USA: Vintage Books; 1999

This book looks at lying and deception in both public and private life — in law, medicine, government, in the family, and between friends. The author, a philosopher, also discusses the justifications for different types of lies and the consequences of each.

Lazare A
New York, New York, USA: Oxford University Press; 2004

An apology to the patient following a medical error or adverse event is an important part of the healing process between caregiver and patient. One of the most profound interactions that can occur between people, apologies have the power to heal humiliations, free the mind from deep-seated guilt, remove the desire for vengeance, and ultimately restore broken relationships. According to the author, all true apologies are a kind of offering intended to restore the dignity and self-respect of the offended party. This book discusses the importance of apology and presents a detailed analysis, including why it is so difficult to apologize and why some apologies heal while others fail.

Improving clinical quality and patient safety of greater importance to not-for-profit hospitals. Special Comment. Moody’s Investor Service. May 2006.

This article reflects the growing importance of clinical quality and patient safety in the eyes of multiple stakeholders: patients, physicians, payers, employers, and hospitals. In the Summary Opinion, the authors write, “Moody’s anticipates that in the short-term, strategies to improve quality and patient safety will likely reduce operating results for many hospitals as the tools and steps to implement the strategy may require adding costs faster than benefits are realized. However, hospitals that eventually demonstrate a sustainable link between quality investments and better clinical outcomes will likely gain competitive advantage, thereby improving financial performance and possibly their bond ratings.”

Copyright Moody's Investor Service, Inc. and/or its affiliates. Reprinted with permission. All rights reserved.   

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Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. The clinical transformation of Ascension Health: Eliminating all preventable injuries and deaths. Joint Commission Journal on Quality and Patient Safety. 2006 June;32(6):299-308.

In 2002 Ascension Health, a 67-hospital not-for-profit health care system, embarked on a journey of clinical transformation to eliminate preventable injuries or deaths. This transformational change implies a much greater pace of change than that reflected in traditional, incremental change processes. Their improvement activities focused on eight priorities for action: JCAHO National Patient Safety Goals; preventable mortality; adverse drug events; falls; pressure ulcers; surgical complications; nosocomial infections; and perinatal safety. [This article is the first in a series.]

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Teach Safe Practices When Using Alcohol-Based Hand Rubs. Joint Commission Resources On-line Safety Alert. May 22, 2006.

A health care worker at a Michigan hospital received a small (2cm) burn to her hand after an electrostatic discharge (ESD) ignited alcohol-based hand rub (ABHR). Improving hand hygiene compliance, including the use of alcohol-based hand rubs, is a major quality and safety initiative in health care. Communication with staff should continue to focus on the importance of compliance, and organizations should remind ABHR users to allow the alcohol to adequately dissipate before contact with any potential source of ESD.

McCarthy D, Blumenthal D. Committed to Safety: Ten Case Studies on Reducing Harm to Patients. The Commonwealth Fund. April 2006; Publication No. 923.

This report presents ten case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas that hold great promise for improving patient safety nationally: promoting an organizational culture of safety; improving teamwork and communication; enhancing rapid response to prevent heart attacks and other crises in hospitals; preventing health care-associated infections in the intensive care unit; and preventing adverse drug events throughout the hospital.

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Schyve PM. Patient safety: Beyond the "easy" phase. The Commonwealth Fund Quality Matters newsletter. April 2006.

According to Paul M. Schyve, MD, Senior Vice President of the Joint Commission on Accreditation of Healthcare Organizations, the good news is that the science, patient safety tools, and our knowledge of safe practices have advanced rapidly since the 1999 Institute of Medicine report on error in health care. Unfortunately, as difficult as this process of change has been, it is the "easy" phase. According to Schyve, developing and maintaining a safe culture is the "hard" phase — the real, underlying challenge to successfully applying safety science and safe practices throughout health care.

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Porche Jr. RA (editor)
Chicago, Illinois: Joint Commission Resources; 2006

This book first lays a foundation by exploring the roots of lean thinking and its migration into US business. The book addresses how lean thinking is being applied to health care, including case examples in reducing waste, challenges leaders face in applying lean to their organization, and how lean principles can be used to meet Joint Commission on Accreditation of Healthcare Organizations standards.

Tucker Al, Spear SJ. Operational failures and interruptions in hospital nursing. Health Services Research [serial online]. 2006.

This article describes a study in which the authors tried to describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care.