**Patient Safety: You Can Make a Difference**

**Recommended Reading for Patients, Families and Patient Advocates**

> Berntsen, Karen J. The *Patient's Guide to Preventing Medical Error*.
> Westport, CT: Praeger; 2004. ISBN: 0275982300.
>
> Bogner, Marilyn Sue, ed. *Human error in medicine*. Hillsdale, NJ:
> Lawrence Erlbaum; 1994. ISBN: 0-80581-385-3.
>
> Dekker S. *Ten questions about human error: a new view of human
> factors and system safety* Boca Raton, FL: CRC; 2004. ISBN: 0805847456
>
> Frankel A, Grillo SP, Baker EG, et al. Patient Safety Leadership
> WalkRounds at Partners Healthcare: learning from implementation. *Jt
> Comm J Qual Patient Saf.* 2005 Aug;31(8):423-37.
> <http://www.coesafety.bwh.harvard.edu/resourcesPages/Publications_Selected.htm>
>
> Gallin, Pamela. *How to Survive Your Doctor\'s Care.* Washington, DC:
> LifeLine Press; 2003. ISBN: 0895261200
>
> Gawande, A. *Complications: a surgeon's notes on an imperfect
> science*. New York; Picador: 2002. ISBN: 0-31242-170-2.
>
> Gibson, Rosemary. Role of the patient in improving patient safety.
> *WebM&M.* 2007(Mar): Perspectives on Safety.
> <http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38>
>
> Giller, Cole A. *Port in the Storm: How to Make a Medical Decision and
> Live to Tell About It.* Washington DC; LifeLine Press. 2003. ISBN:
> 0-89526-132-4.
>
> Hicock L, Lewis J. *Beware the grieving warrior: a child\'s
> preventable death. a struggle for truth, healing, and change.*
> Toronto; ECW Press, 2004. ISBN: 1550226738
>
> Kalb C. Fixing America's hospitals. *Newsweek.* October 16, 2006;
> 44--68. <http://www.newsweek.com/id/44975>
>
> Munch, D. Patients and families can offer key insights in root cause
> analyses. *Focus Patient Safety*. 2004;7(4):6-7.
> <http://www.npsf.org/download/Focus2004Vol7No4.pdf>
>
> Roizen, MF, Oz MC. *You: the smart patient: an insider\'s handbook for
> getting the best treatment*. New York, Free Press, 2006. ISBN:
> 0743293010
>
> Patient and Family Advisory Council. *National agenda for action:
> patients and families in patient safety: nothing about me, without
> me.* North Adams, MA: NPSF; 2003.
> <http://www.npsf.org/download/AgendaFamilies.pdf>
>
> *Role of the patient advocate: a consumer fact sheet*. McLean, VA:
> NPSF; 2003. <http://www.npsf.org/download/PatientAdvocate.pdf>
>
> Segen, JC, Stauffer J, Wade, J. *Patient\'s guide to medical tests:
> everything you need to know about the tests your doctor prescribes*.
> New York: Checkmark Books; 2002. ISBN: 0816046522.
>
> Tugend, A. Going to the hospital? don\'t forget to pack a nurse. *New
> York Times*. September 17, 2005.
> <http://www.nytimes.com/2005/09/17/business/17shortcuts.ready.html>

Additional Reading Lists:

> AHRQ: <http://psnet.ahrq.gov/content.aspx?taxonomyID=222>
>
> CAPS: <http://www.patientsafety.org/page/99518/>
>
> Josie King Foundation: <http://www.josieking.org/page.cfm?pageID=44>
>
> PPECA: <http://www.galter.northwestern.edu/ppeca/reading_list.htm>

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**Patient Safety: You Can Make a Difference**

**Presentation Bibliography**

Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in Laboratory
Medicine. *Clin Chem*, 2002(May); 48(5):691-698.
<http://www.clinchem.org/cgi/content/full/48/5/691>

Committee on Data Standards for Patient Safety, Board on Health Care
Services. *Patient safety: achieving a new standard for care.*
Washington, DC: National Academies Press; 2004:30,32,34. \#
0-309-0977-6. <http://books.nap.edu/catalog/10863.html>

Cosby KS, Croskerry P. Profiles in patient safety: authority gradients
in medical error. *Acad Emerg Med.* 2004(Dec);11(12):1341-1345.

DeLisa JA. Physiatry: medical errors, patient safety, patient injury,
and quality of care. *Am J Phys Med Rehabil.* 2004(Aug);83(8):575-583

Frankel A, Graydon Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK.
Patient safety leadership walkrounds. *Jt Comm J Qual Safety.*
2003(Jan);29(1):16-26.

Frankel A, Haraden C. Shuttling toward a safety culture. Healthcare can
learn from probe panel\'s findings on the Columbia disaster. *Mod
Healthc*. 2004(Jan 5);34(1):21.

Furman C, Caplan R. Applying the Toyota Production System: using a
patient safety alert system to reduce error. *Jt Comm J Qual Patient
Saf.* 2007 Jul;33(7):376-386.

Gibson, Rosemary. Role of the patient in improving patient
safety.*WebM&M.* 2007(Mar): Perspectives on Safety.
<http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38>

Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of
communication breakdowns resulting in injury to surgical patients. *J Am
Coll Surg*. 2007 Apr;204(4):533-540.

Hippocrates. *Of the Epidemics*, Bk. I:Sect. XI.c. 400 BC. In:
*Hippocrates: with an English translation by W. H. S. Jones*. Loeb
Classical Library, Vol 1. Cambridge, Mass: Harvard University Press;
1923:165.

James C. Manufacturing\'s prescription for improving healthcare quality.
*Hosp Top.* 2005 Winter;83(1):2-8.

Joint Commission. \[*Look-alike/sound-alike drug list\]*. Oakbrook
Terrace, Ill: Joint Commission on Accreditation of Healthcare
Organizations; 2006.
<http://www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf>

Joint Commission. *Sentinel Event*; 2008.
<http://www.jointcommission.org/SentinelEvents/>

Kalra J. Medical errors: impact on clinical laboratories and other
critical areas. *Clin Biochem.*2004(Dec);37(12):1052-1062.

Kao LS, Thomas EJ. Navigating towards improved surgical safety using
aviation-based strategies. *J Surg Res*. 2007 May 1 (e-pub)

Kohn LT, Corrigan JM, Donaldson MS. *To err is human: building a safer
health system*. Washington, DC: National Academy Press; 2000.
<http://books.nap.edu/catalog/9728.html>

Kozer E, Scolnik, Macpherson A., et al. Variables Associated With
Medication Errors in Pediatric Emergency Medicine. *Pediatrics,*
2002(Oct);110(4):737-742.

Lesar TS. Errors in the use of medication dosage equations. *Arch
Pediatr Adolesc Med* 1998(Apr);152(4):340--344.

Levis RJ. Traditional Errors in Surgery. Presidential Address to the
Medical Society of the State of Pennsylvania on June 6, 1888. *JAMA*.
1888 (Jun 23);10(25):790-791.

Matlow AG, Berte L. Sources of error in laboratory medicine. *Lab Med.*
2004(Jun);35(6):331-334.

McDonald CJ. Computerization can create safety hazards: a bar-coding
near miss. *Ann Intern Med.* 2006(Apr 4);144(7):510-6.
<http://www.annals.org/cgi/content/full/144/7/510> (free registration
required)

MMS Committee on Quality of Medical Practice and Trinity Communications,
Inc*. Medical Errors and Perspectives on Patient Safety.* Massachusetts
Medical Society, 2007.
<http://www.massmed.org/Content/ContentGroups/SectionsTopics/ContinuingEducation/OnlineCME/MedicalErrorsandPerspectivesonPatientSafety/MedicalErrorsCourseMaterials.pdf>

Munch, D. Patients and families can offer key insights in root cause
analyses. *Focus Patient Safety*. 2004;7(4):6-7.
<http://www.npsf.org/download/Focus2004Vol7No4.pdf>

Reason J. Human error: models and management. *BMJ* 2000;320;768-770.
<http://www.bmj.com/cgi/content/full/320/7237/768>

Renner SW, Howanitz PJ, Bachner P. Wristband identification error
reporting in 712 hospitals: a College of American Pathologists' Q-Probes
Study of Quality Issues in Transfusion Practice. *Arch Pathol Lab Med.*
1993(Jun);117(6):573-7.

*Role of the patient advocate: a consumer fact sheet*. McLean, VA: NPSF;
2003. <http://www.npsf.org/download/PatientAdvocate.pdf>

Savill, R. Staff shortage led to death of patient. *Daily Telegraph.*
March 12, 2005:13

Sazama K. Reports of 355 transfusion-associated deaths: 1976 through
1985. *Transfusion.* 1990(Sep);30(7):583-590.Scarsi KK, Fotis MA, Noskin
GA. Pharmacist participation in medical rounds reduces medication
errors. *Am J Health Syst Pharm.* 2002(Nov 1);59(21):2089-2092.

Shapiro JP. Taking the mistakes out of medicine: Minnesota Children's
remakes its culture in the name of safety. *US News World Rep.* 2000(Jul
17);129(3):50-53,56,58,64-64,66.

Spencer FC. Human error in hospitals and industrial accidents: current
concepts. *J Am Coll Surg.* 2000 Oct;191(4):410-418.

Taffinder NJ, McManus IC, Gul Y, Russell RC, Darzi A. Effect of sleep
deprivation on surgeons\' dexterity on laparoscopy simulator .Lancet.
1998 (Oct 10); 352(9135):1191‑1192.

Thomas M, Morton R, Mackway-Jones K. Identifying and comparing risks in
emergency medicine. *Emerg Med J*. 2004 Jul;21(4):469-72.

Trzeciak S, Rivers EP. Emergency department overcrowding in the United
States: an emerging threat to patient safety and public health. *Emerg
Med J*. 2003 Sep;20(5):402-5.
<http://emj.bmj.com/cgi/content/full/20/5/402> (free registration
required)

Turnbull JE. Systems approach to error reduction in health care. *Japan
Med Assoc J.* 2001(Sep); 44(9): 392-403.
<http://www.med.or.jp/english/pdf/jmaj/v44no09.pdf>

Ulrich R, Zimring C. *Role of the physical environment in the hospital
of the 21st century: a once in a lifetime opportunity.* Princeton, NJ:
Robert Wood Johnson Foundation; 2004.
<http://www.rwjf.org/files/publications/other/RoleofthePhysicalEnvironment.pdf>

Webster CS. Nuclear power industry as an alternative analogy for safety
in anaesthesia and a novel approach for the conceptualisation of safety
goals. *Anaesthesia* 2005 Nov;60(11):1115-22.

Wilson C. Premature infants died following apparent drug overdose.
*News-Sentinel* Oct 17, 2006.

Yee P. Brain cramp: the emergency physician\'s worst nightmare. *Ann
Emerg Med*. 2002(Mar);39(3):329-330.

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| (media/i | Greater Midwest Region**                           | ted: |
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| 3125in"} | Health Science*s                                   |      |
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