When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; March 2006.

This consensus paper of the Harvard-affiliated hospitals proposes a full disclosure when adverse events or medical errors occur, including an apology to the patient. The paper represents the collaborative effort of a group of clinicians, risk managers, and patients participating from several Harvard teaching hospitals and the Risk Management Foundation.

Full text available! Click view report below.

Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety. Mar 2006;32(3):167-175.

The importance of sharing a common mental model in communication prompted efforts to spread the use of the SBAR (Situation, Background, Assessment, and Recommendation) tool at OSF St. Joseph Medical Center in Bloomington, Illinois.

Full text available! Click view article below.

Gray JE, Suresh G, Ursprung R, et al. Patient misidentification in the neonatal intensive care unit: Quantification of risk. Pediatrics. 2006 Jan;117(1):e43-47.

This article describes a study which intended to quantify the potential for misidentification among Neonatal Intensive Care Unit patients resulting from similarities in patient names or hospital medical record numbers (MRNs). The study concluded that there is significant risk of misidentification in the NICU.

Kaplan M. Front page news. Modern Healthcare. Nov 2005;35(48).

IHI's Madge Kaplan traces the journey of the media coverage of health care quality, specifically it's focus on patient safety.

Full text available! Click View article below

Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Annals of Internal Medicine. Apr 2005;142(8):627-630.

This article contends that there are two differences between error prone organizations and high performing teams. First, high performers know how to limit the consequences of errors, and secondly, they know how to prevent them from reoccurring. 

Berman S (editor)
Chicago, Illinois: Joint Commission Resources and the Institute for Healthcare Improvement; 2005

Health care leaders are now finding quality and safety to be vital not only to the health of patients but also to the health of the enterprise. In this book, the experts widely considered top in their respective fields describe the most challenging issues facing health care leaders today and provide guidance and suggestions on how to address them. Topics include microsystem peak performance; organizational infrastructure for patient safety; using information technology for safety and quality; patient flow; staffing for organizational excellence; and strategies to spread improvement.

Schoen C, Osborn R, Huynh PT, et al. Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Health Affairs. Nov 2005; [Epub ahead of print].

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions.

Spear SJ. Fixing health care from the inside, today. Harvard Business Review. 2005 Sep;83(9):78-91.

How can health care professionals ensure that the quality of their service matches their knowledge and aspirations? As a number of hospitals and clinics have discovered, learning how to improve the work you do while you actually do it can offer extraordinary savings in lives and dollars.

Øvretveit J. The leader's role in quality and safety improvement: A review of research and guidance. Swedish Association of County Councils. 2004.

The Swedish Association of County Councils, Stockholm (Lanstingsforbundet), has produced this review of research and guidance in order to further develop its leaders for Quality and Safety Improvement.  The report speaks to the body of research conducted on the leadership role and provides evidenced-based guidance and checklists to help leaders advance their quality and safety agendas.

*The article is linked here with permission from the Swedish Association of County Councils.

Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.

IHI Innovation Series white paper

Leadership is the critical element in a successful patient safety program and for building a culture of safety, and is non-delegable. This white paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations. Each step and its component parts are described in detail, and resources for more information are provided where available.

Full text available! Click view white paper below.