Systems Based Practice

2013 Ten ways to improve pt. safety from the AHRQ

http://www.ahrq.gov/legacy/qual/10tips.htm

Patient Safety

The case of Mary McClinton at the Virginia Mason Medical Center

http://www.donnunn.com/spiel/2004/11/seattle_times_h.html

References:

Books and Articles I would recommend on Quality and Patient Safety are:

The Cost Conundrum - Atul Gawande discusses the incentives for medicare spending

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

Personal Best -Atul Gawande

http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande

Cowboys and Pit Crews - Atul Gawande

http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html

I recommend all of Dr. Gawande's books:

Complications

Better

Checklist Manifesto

Being Mortal

If you like the books, you will like the content on Dr. Gawande's website

http://gawande.com

IHI Open School has courses on system issues issueshttp://www.ihi.org/offerings/IHIOpenSchool/Pages/default.aspx

Fatigue/Sleep deprivation

http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?_r=2&pagewanted=1&sq=libby%20zion&st=cse&scp=1

Forgive and Remember 2nd Edition (2003) - Charles Bosk

This is the reference for the "horror story" method of teaching.

On its initial publication, Forgive and Remember emerged as the definitive study of the training and lives of young surgeons. Now with an extensive new preface, epilogue, and appendix by the author, reflecting on the changes that have taken place since the book's original publication, this updated second edition of Charles L. Bosk's classic study is as timely as ever. (I reviewed the first edition (1979) as a college student, before they invented systems based practice)

http://www.amazon.com/Forgive-Remember-Managing-Medical-Failure/dp/0226066789

Just Culture - Sidney Dekker

http://www.amazon.com/Just-Culture-Balancing-Safety-Accountability/dp/0754672670

Whack-a-mole - David Marx

http://www.amazon.com/Whack-Mole-Price-Expecting-Perfection/dp/0615283071/ref=pd_sim_b_2

Neuroradiology in the News (Patient Safety)

Pt had neurosurgery on the wrong side, wrong films brought to the OR

http://www.nytimes.com/1995/06/25/nyregion/surgery-is-done-on-wrong-side-of-a-brain.html

Paul Nagy, PhD has a list of books that he recommends at

http://www.librarything.com/catalog/pnagy&tag=quality

A shorter list was included in the JACR

http://www.jacr.org/article/S1546-1440(09)00644-9/abstract

(attached below)