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