Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? Journal of the American Medical Association. 2005 May 18;293(19):2384-2390.

The Institute of Medicine (IOM) called for a national effort to make health care safe in its landmark 1999 report, To Err Is Human. The authors assert that, while progress is underway, improvement of the magnitude and pace envisioned by the IOM requires a level of national focus and commitment still lacking.

Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units. BMC Health Services Research. Apr 2005;5(1):28 [Epub ahead of print].

A randomized control trial was conducted by a group of experts in the subject of Executive Walkrounds and measurement of safety climate attitudes. The study looked specifically at how walkrounds affected nurses, as measured with safety climate surveys.

Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care. 2003 Dec;12 Suppl 2:39-45.

This article describes a new method of measuring harm called the Trigger Tool. The Trigger Tool is easily customized and can be readily taught, enabling consistent and accurate measurement of harm. The history, application, and impact of the trigger tool concept in identifying and quantifying harm are discussed.

Draper S, Nielsen GA, Noland M. Using "no problem found" in infusion pump programming as a springboard for learning about human factors engineering. Joint Commission Journal of Quality and Safety. 2004;30(9):515-520.

Case illustrates that efforts to maximize device customization or simplification can have negative human factors engineering consequences.  The decision to allow for function overrides or nontraditional equipment use must be weighed against the potential compromises in patient safety.

Lamb R. Open disclosure: The only approach to medical error. Quality and Safety in Health Care. 2004;13:3-5.

This is a discussion about the importance of open disclosure of medical errors in promoting and achieving improved patient safety.

Draper S, Nielsen GA, Noland M. Using "no problem found" in infusion pump programming as a springboard for learning about human factors engineering. Joint Commission Journal of Quality and Safety. 2004;30(9):515-520.

Case illustrates that efforts to maximize device customization or simplification can have negative human factors engineering consequences.  The decision to allow for function overrides or nontraditional equipment use must be weighed against the potential compromises in patient safety.

Wachter RM. The end of the beginning: Patient safety five years after ‘To Err Is Human’. Health Affairs Web Exclusive. Nov 2004.

This article argues that since the release of the IOM report "To Err Is Human" in 1999 there has been progress, but it has been insufficient.  Five years after the report’s publication, the author contends that we appear to be at “the end of the beginning.”

Spath PL, Nash DB
Chicago, Illinois: American Hospital Association; 2004

A guide to involving patients in error prevention and the role of hospital leadership.

Five years ago, the Institute of Medicine released its landmark report, "To Err Is Human," which moved patient safety into the national spotlight.  IHI hosted a STAT Call, with many of those involved with the report on November 12 to reflect on the progress made and how to accelerate the pace of change.  Below is a written transcript of that call.

Young GJ, Charns MP, Daley J, Forbes MG, Henderson W, Khuri SF. Best practices for managing surgical services: The role of coordination. Health Care Management Review. 1997;22(4):72-81.

This article describes a National Veterans Affairs Surgical Risk Study, in which the authors studied the coordination practices of 20 surgical services that, based on risk-adjusted mortality and morbidity rates, occupied different ends of the patient outcomes continuum.