Recommended Reading

WHO Patient Safety Curriculum Guide for Medical Schools – Executive Summary

General Reading on Patient Safety

1. Leape LL. Safe health care: are we up to it? BMJ2000;320:725-726
2. Leape LL. A series on patient safety. Editorial NEJM 2002;347:16:1272-4
3. Reinertsen JL Let’s talk about error. BMJ2000;320:730
4. Brennan TA, Leape LL,Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. NEJM 1991; 324(6):370-376
5. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients. N Engl.J Med 1991; 324(6): 377-84
6. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care.2000; 38(3):261-271
7. Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ 1998; 316: 1154-57
8. Kohn LT, Corrigan JM, Donaldson MS, eds. 1999. To Err is Human: Building a Safer Health Care System. National Academy Press, Washington, DC.
9. Baker GR, Norton PG, Flintoft V et al. The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada CMAJ 2004; 170 (11): 1678-86
10. Weingart SN, McL Wilson R, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ 2000; 320: 774-777
11. Miller M, Elixhauser A, Zhan C. Patient safety events during pediatric hospitalizations. Pediatrics. 2003; 111:6:1358-1366
12. Miller.M and Zhan C. Pediatric patient safety in hospitals: a national picture in 2000. Pediatrics 2004; 113:6:1741-1746
13. Woods D, Thomas E, Holl J, Altman S, Brennan T. Adverse events and preventable adverse events in children. Pediatrics 2005; 115(1): 155-160.
14. McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Preventable adverse events in infants hospitalized with bronchiolitis. Pediatrics 2005; 116(3): 603-608.
15. Proctor ML, Pastore J, Gerstle JT, Langer JC. Incidence of medical error and adverse outcomes on a pediatric general surgery service. J Ped Surg 2003;38(9):1261-1265

Readings Related to High Reliability Organizations:

1. Weick: Managing the Unexpected: High Reliability Organizations - Available from Amazon Books - $19.97
2. Reason J. Human error: models and management. BMJ 2000;320: 768-770
3. Accreditation Canada Patient Safety ROPs
4. IHI White Papers - Supports the characteristics and capacities of organizations

Readings Related to Identification of Adverse Events:

1. Thomas EJ and APetersen LA. Measuring Errors and Adverse Events in Health Care. J Gen Intern Med 2003;18:61-67.
2. Thomas EJ et al. The Reliability of Medical Record Review for Estimating Adverse Event Rates. Ann Intern Med. 2002;136:812-816.
3. Building a Safer System: Canadian Adverse Event Reporting and Learning System consultation paper - CPSI website
4. Takata GS et al. Development, Testing, and Findings of a Pediatric-Focused Trigger Tool to identify Medication-Related Harm in US
5. Children's Hospitals. Pediatrics 2008;121;e927-935
   Rear RK, Rozich JD and Classen D. Metholdology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003;12;suppl(2):ii39-ii45.
6. Ferranti et al. Reevaluating the Safety Profile of Pediatrics: A comparison of computerized adverse drug event surveillance and voluntary reporting in the Pediatric environment. Pediatrics 2008;121;e1201-1207.
7. Ali Baba-Akbari Sari et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospitalL retrospective patient case note review. BMJ 2007;334;79-84.
8. IHI Global Trigger Tool for measuring adversent events 2nd edition, 2009. IHI website
9. Matlow A, Flintoft V, Orrbine E, Brady-Fryer B, Cronin M.G., Nijssen-Jordan C, Fleming M, Hiltz M-A, Lahey M, Zimmerman M, Baker GR. The development of the Canadian paediatric trigger tool for identifying potential adverse events.

Readings Related to Managing Safety Risks

1. Human error: models and management. James Reason. BMJ 2000
2. Managing the Unexpected. Weick and Sutcliffe. 2007. Wiley Books. (extra)
3. Leonard MS et al. Risk Reduction for Adverse Drug Events Through Sequential Implementation of Patient Safety Initiatives in a Children’s Hospital. Pediatrics 2006.

Readings Related to Optimizing Human and Environmental Factors

1. Lockley et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1829-1837.
2. Landrigan et al. Effect of reducint interns' work hours on serious medical errors in intensive care units. NEJM 2004Oct28;351(18):1838-1848.
   
3. Landrigan et al. Interns' compliance with accreditation council for medical education work-hours limits. JAMA 2006Sept6;296(9):1063-1070.
4. Lockely et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual patient safety 2007 Nov;33(11 Suppl):7-18.
5. Landrigan et al. Effective implementaiton of work-hour limits and systemic improvements. Jt Comm J Qual patient safety 2007 Nov;33(11 Suppl):19-29.
6. Fahrenkopf AM et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008 Mar1;336(7642):488-491.
7. Janney M, Landrigan C. Improving nurse working conditions: towards safer models of hospital care. J Hosp Med. 2008 May:3(3):181-183.
8. Landrigan et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics 1008Aug;122(2):250-258.
9. Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA. 2008 Sep 10;300(10):1197-1199
10. Reason’s article Qual Saf Health care 1995; 4:80-89
11. Vincent et al BMJ 1998;316:1154-57
12. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med
    2003;78:775–80.
13. Croskerry PG. The cognitive imperative: thinking about how we think. Acad Emerg Med 2000;7(11):1223–31.
14. Norman DA. The design of everyday things. New York: Basic Books; 1988.
15. Vicente K. The human factor: revolutionizing the way people live with technology. Toronto: Knopf; 2003
    This web site has a downloadable power point deck and support material
16. Reason J. Beyond the organizational accident: the need for “error wisdom” on the frontline. Qual Saf Health Care 2004; 13:ii28-ii33
    Reason presents a case of vincristine given intrathecally to an 18 year old patient who died 3 weeks later. He analyzes all the underlying issues but makes a plea for training frontline nurses and doctors in error preparedness in order to instill ‘informed vigilance and intelligent wariness in those at the sharp end’.
    This includes:
    • Accept that errors can and will occur
    • Assess the local bad stuff before embarking on a task
    • Have contingencies ready to deal with anticipated problems
    • Be prepared to seek more qualified assistance
    • Do not let professional courtesy get in the way of checking your colleagues’ knowledge and experience, especially when they are strangers
    • Appreciate that the path to adverse events is paved with false assumptions

Readings Related to Recognizing, Responding to, and Disclosing Adverse Events

1. CMPA Disclosure Toolkit
2. CPSI Canadian Disclosure Guidelines - includes PDF version and list of Provincial Speakers on Disclosure and a PowerPoint Presentation
3. Health Quality Council of Alberta. Disclosure of Harm to Patients and FAmilies - Provincial Framework
4. College of Physicians and Surgeons of Ontario. Disclosure of Harm Policy
5. Provincial Disclosure Legislation and Apology Acts - official versions must be obtained from Statutory Publication
6. DVD - Removing Insult From Injury; Disclosing Adverse Events - available for $99.95 US + shipping
7. Capital Health Disclosure Guide - PDF Attached
8. 2006-BC Apology Act.pdf
9. 2006 2nd Reading Debate - BC Apolgy Act.pdf
10. Apology Act 5.pdf
11. Bill 103 - Yukon Apology Act.pdf
12. Bill 202 Manitoba Apology Act.pdf
13. Discussion_Apology_Legislation.pdf
14. List of USA Apology Acts & Mandatory Reporting of AEs.pdf