Implementation of patient safety initiatives in US hospitals

International Journal of Operations and Production Management

Volumn 26, Issue 3, 2006, Pages 326-347

  McFadden, Kathleen L ^a   Stock, Gregory N ^a   Gowen III, Charles R ^a  

^a NORTHERN ILLINOIS UNIVERSITY   (United States)

Author keywords

Health and safety; Hospitals; Patient care; Patients; United States of America

Indexed keywords

EID: 33644597576     PISSN: 01443577     EISSN: None     Source Type: Journal    
DOI: 10.1108/01443570610651052     Document Type: Article

References (86)

1. Ahire, S.L., Golhar, D.Y. and Waller, M.A. (1996), "Development and validation of TQM implementation constructs", Decision Sciences, Vol. 27 No. 2, pp. 23-56.
2. American Hospital Association (2002), "Teaching hospitals - social missions at risk", Trend Watch, Vol. 4 No. 2, p. 1.
3. Baker, G.R. and Norton, P.G. (2004), "Adverse events and patient safety in Canadian health care", Canadian Medical Association, Vol. 170 No. 3, pp. 353-4.
4. Barry, R., Murcko, A.C. and Brubaker, C.E. (2002), The Six Sigma Book for Healthcare, Health Administration Press, ACHE Management Series, Chicago, IL.
5. Bates, D.W., Leape, L.L., Cullen, D.J., Laird, N., Petersen, L.A., Teich, J.M., Burdick, E., Hickey, M., Kleefield, S., Shea, B., Vliet, M.V. and Seger, D.L. (1998), "Effect of computerized order entry and a team intervention on prevention of serious medication errors", Journal of the American Medical Association, Vol. 280 No. 15, pp. 1311-6.
6. Becher, E.C. and Chassin, M.R. (2001), "Improving quality, minimizing error: making it happen", Health Affairs, Vol. 20 No. 3, pp. 68-81.
7. Bedard, J.C. and Johnson, A.C. (1984), "The organizational effectiveness paradigm in health care management", Health Care Management Review, Vol. 9 No. 4, pp. 67-75.
8. Black, S.A. and Porter, L.J. (1996), "Identification of the critical factors of TQM", Decision Sciences, Vol. 27 No. 1, pp. 1-21.
9. Bretthauer, K.M. (2004), "Service management", Decision Sciences, Vol. 35 No. 3, pp. 325-32.
10. Bushell, S. and Shelest, B. (2002), "Discovering lean thinking at progressive healthcare", Journal for Quality & Participation, Vol. 25 No. 2, pp. 20-5.
11. Busse, D.K. and Johnson, C.W. (1999), "Identification and analysis of incidents in complex, medical environments", Proceedings of the First Workshop on Human Error and Clinical Systems, Glasgow, UK.
12. Carey, R.G. (2003), Improving Healthcare with Control Charts, ASQ Press, Milwaukee, WI.
13. Carey, R.G. and Lloyd, R.C. (2001), Measuring Quality Improvement in Healthcare: A Guide to Statistical Process Control Applications, ASQ Press, Milwaukee, WI.
14. Ceniceros, R. (2002), "Reporting errors poses risks", Business Insurance, Vol. 36 No. 41, pp. 2-27.
15. Chassin, M.R. and Becher, E.C. (2002), "The wrong patient", Annals of Internal Medicine, Vol. 136 No. 11, pp. 826-33.
16. Chiang, M. (2001), "Promoting patient safety: creating a workable reporting system", Yale Journal on Regulation, Vol. 18 No. 2, pp. 383-408.
17. Coffin, B. (2002), "Seeking a cure for medical errors liability", Risk Management, Vol. 49 No. 10, pp. 8-9.
18. Cooper, J.B., Newbower, R.S. and Kitz, R.J. (1984), "An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection", Anesthesiology, Vol. 60 No. 1, pp. 34-42.
19. Cooper, J.B., Newbower, R.S., Long, C.D. and McPeek, B. (1978), "Preventable anesthesia mishaps: a study of human factors", Anesthesiology, Vol. 49 No. 6, pp. 399-406.
20. Cronbach, L.J. (1951), "Coefficient alpha and the internal structure of tests", Psychometrika, Vol. 16, pp. 297-334.
21. Davis, P., Lay-Yee, R., Fitzjohn, J., Hider, P., Briant, R. and Schug, S. (2002), "Compensation for medical injury in New Zealand: does 'no fault' increase the level of claims making and reduce social and clinical selectivity?", Journal of Health Politics, Policy, and Law, Vol. 27 No. 5, pp. 833-54.
22. Deming, W.E. (1986), Out of the Crisis, Massachusetts Institute of Technology, Center for Advanced Engineering Study, Cambridge, MA.
23. Doolan, D.F. and Bates, D.W. (2002), "Computerized physician order entry systems: mandates and incentives", Health Affairs, Vol. 21 No. 4, pp. 180-8.
24. Douglas and Fredendall (2004), "Evaluating the Deming management model of total quality in services", Decision Sciences, Vol. 35 No. 3, pp. 393-422.
25. Dunteman, G.H. (1989), Principal Component Analysis, Sage, Newbury Park, CA, (Sage University Paper series on Quantitative Applications in the Social Sciences, No. 07-069).
26. Dutton, J.E. and Duncan, R.B. (1987), "The creation of momentum for change through the process of strategic issue diagnosis", Strategic Management Journal, Vol. 8 No. 3, pp. 279-95.
27. Edmondson, A.C. (1996), "Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error", Journal of Applied Behavioral Science, Vol. 32 No. 1, pp. 5-28.
28. Edmondson, A.C. (1999), "Psychological safety and learning behavior in work teams", Administrative Science Quarterly, Vol. 44 No. 2, pp. 350-83.
29. Fiesta, J. (1998), "Target high-risk areas for medication errors", Nursing Management, Vol. 29 No. 12, pp. 12-13.
30. Flynn, B.B. and Saladin, B. (2001), "Further evidence on the validity of the theoretical models underlying the Baldrige criteria", Journal of Operations Management, Vol. 19 No. 6, pp. 617-52.
31. Flynn, B.B., Sakakibara, S., Schroeder, R.G., Bates, K.A. and Flynn, E.J. (1990), "Empirical research methods in operations management", Journal of Operations Management, Vol. 9 No. 2, pp. 250-84.
32. Gaba, D.M. (2001), "Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries", California Management Review, Vol. 43, pp. 83-102.
33. Gaba, D.M., Singer, S.J., Sinaiko, A.D., Bowen, J.D. and Ciavarelli, A.P. (2003), "Differences in safety climate between hospital personnel and naval aviators", Human Factors, Vol. 45 No. 2, pp. 173-85.
34. Huq, Z. and Martin, T.N. (2000), "Workforce cultural factors in TQM/CQI implementation in hospitals", Health Care Management Review, Vol. 25 No. 3, pp. 80-93.
35. Institute of Medicine (2000), To Err is Human, Building a Safer Health System, National Academy Press, Washington, DC.
36. Institute of Medicine (2001), Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press, Washington, DC.
37. Johnston, R. (2002), "Linking complaint management to profit", International Journal of Service Industry Management, Vol. 12 No. 1, pp. 60-9.
38. Kaiser, H.F. (1960), "The application of electronic computers to factor analysis", Educational and Psychological Measurement, Vol. 20, pp. 141-51.
39. Klein, D., Motwani, J. and Cole, B. (1998), "Quality improvement efforts at St Mary's hospital: a case study", Managing Service Quality, Vol. 8 No. 4, pp. 235-40.
40. Kovner, C. and Gergen, P.J. (1998), "Nurse staffing levels and adverse events following surgery in US hospitals", Image: Journal of Nursing Scholarship, Vol. 30 No. 4, pp. 315-21.
41. Kumar, K. and Subramanian, R. (1998), "Meeting the expectations of key stakeholders: stakeholder management in the health care industry", SAM Advanced Management Journal, Vol. 63 No. 2, pp. 31-9.
42. Leape, L.L. (1994), "Error in medicine", Journal of the American Medical Association, Vol. 272, pp. 1851-7.
43. Leape, L.L. (1996), "Hospitals begin to take mistakes seriously", Health Systems Review, Vol. 29 No. 6, pp. 21-4.
44. Leape, L.L., Bates, D.W., Cullen, D.J., Cooper, J., Demonaco, H.J., Gallivan, R., Hallisey, R., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Petersen, L.A., Porter, K., Servi, D., Shea, B.F., Small, S.D., Sweitzer, B.J., Thompson, B.T. and Vliet, M.V. (1995), "Systems analysis of adverse events", Journal of the American Medical Association, Vol. 274 No. 1, pp. 35-43.
45. Li, L. and Benton, W.C. (2003), "Hospital capacity management decisions: emphasis on cost control and quality enhancement", European Journal of Operational Research, Vol. 146 No. 3, pp. 596-614.
46. Liang, B.A. (1999), "Error in medicine: legal impediments to US reform", Journal of Health Politics, Policy, and Law, Vol. 24 No. 1, pp. 27-58.
47. Lim, M.K. (2004), "Quest for quality care and patient safety: the case of Singapore", Quality & Safety in Health Care, Vol. 13, pp. 71-5.
48. McCallion, G., Glass, J.C., Kerr, C.A. and McKillop, D.G. (2000), "Investigating productivity change and hospital size: a nonparametric frontier approach", Applied Economics, Vol. 32 No. 2, pp. 161-74.
49. McFadden, K.L. and Towell, E.R. (1999), "A framework for studying airline safety in the new millennium", Journal of Air Transport Management, Vol. 5, pp. 177-84.
50. McFadden, K.L., Towell, E.R. and Stock, G.N. (2004), "Critical success factors for controlling and managing hospital errors", Quality Management Journal, Vol. 11, pp. 61-74.
51. Morash, E.A., Droge, C. and Vickery, S.K. (1996), "Strategic logistics capabilities for competitive advantage and firm success", Journal of Business Logistics, Vol. 17 No. 1, pp. 1-22.
52. Mullins, D. and Schmele, J.A. (1993), "Reconsideration of the quality circle process as a contemporary management strategy", Health Care Supervisor, Vol. 12 No. 1, pp. 14-22.
53. Nahm, A.Y., Vonderembse, M.A. and Koufteros, X.A. (2004), "The impact of organizational culture on time-based manufacturing and performance", Decision Sciences, Vol. 35 No. 4, pp. 579-607.
54. Newman, K. (1997), "Re-engineering for service quality: the case of leicester royal infirmary", Total Quality Management, Vol. 8 No. 5, pp. 255-64.
55. Nunnally, J.C. (1967), Psychometric Theory, McGraw-Hill, New York, NY.
56. Nutt, P.C. (1987), "Identifying and appraising how managers install strategy", Strategic Management Journal, Vol. 8 No. 1, pp. 1-14.
57. Pelletier, P.L. (2001), "Medication errors: a lesson from long-term care", Nursing Management, Vol. 32 No. 11, pp. 49-50.
58. Plsek, P.E. (1995), "Techniques for managing quality", Hospital & Health Services Administration, Vol. 40 No. 1, pp. 50-79.
59. Podsakoff, P.M. and Organ, D.W. (1986), "Self-reports in organizational research: problems and prospects", Journal of Management, Vol. 12 No. 4, pp. 531-44.
60. Ramamurthy, K. (1995), "The influence of planning on implementation success of advanced manufacturing technologies", IEEE Transactions on Engineering Management, Vol. 42 No. 1, pp. 50-61.
61. Reason, J. (1990), Human Error, Cambridge University Press, Cambridge, MA.
62. Roberts, K.H. (1990), "Some characteristics of high reliability organizations", Organization Science, Vol. 1 No. 2, pp. 160-77.
63. Saraph, J.V., Benson, P.G. and Schroeder, R.G. (1989), "An instrument for measuring the critical factors of quality management", Decision Sciences, Vol. 20 No. 4, pp. 810-29.
64. Small, M.H. and Yasin, M.M. (1997), "Advanced manufacturing technology: implementation policy and performance", Journal of Operations Management, Vol. 15 No. 4, pp. 349-70.
65. Thompson, D.N., Wolf, G.A. and Spear, S.J. (2003), "Driving improvement in patient care: lessons from Toyota", Journal of Nursing Administration, Vol. 33 No. 11, pp. 585-95.
66. Tucker, A.L. (2004), "The impact of operational failures on hospital nurses and their patients", Journal of Operations Management, Vol. 22, pp. 151-69.
67. Tucker, A.L. and Edmondson, A.C. (2003), "Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change", California Management Review, Vol. 45 No. 2, pp. 55-72.
68. Uribe, C.L., Schweikhart, S.B., Pathak, D.S., Marsh, G.B. and Fraley, R.R. (2002), "Perceived barriers to medical-error reporting: an exploratory investigation", Journal of Healthcare Management, Vol. 47 No. 4, pp. 263-80.
69. Vanderveen, L. (1991), "CQI system puts process into improving hospital", Health Care Strategic Management, Vol. 9 No. 2, pp. 16-18.
70. Vickery, S.K., Droge, C. and Markland, R.E. (1993), "Production competence and business strategy: do they affect business performance", Decision Sciences, Vol. 24 No. 2, pp. 435-55.
71. Walshe, K., Bennett, J. and Ingram, D. (1995), "Using adverse events in health-care quality improvement: results from a British acute hospital", International Journal of Health Care Quality Assurance, Vol. 8 No. 1, pp. 7-14.
72. Weick, K.E., Sutcliffe, K.M. and Obstfeld, D. (1999), "Organizing for high reliability: process of collective mindfulness", Research in Organizational Behavior, Vol. 21, pp. 81-123.
73. Wilson, R.M., Runciman, W.B., Gibberd, R.W., Harrison, B.T., Newby, L. and Hamilton, J.D. (1995), "The quality in Australian health care study", The Medical Journal of Australia, Vol. 163 No. 6, pp. 458-71.
74. Woodhouse, S., Burney, B. and Coste, K. (2004), "To err is human: improving patient safety through failure mode and effect analysis", Clinical Leadership and Management Review, Vol. 18 No. 1, pp. 32-6.
75. Bard, M.R. (1994), "Reinventing health care delivery", Hospital & Health Services Administration, Vol. 39 No. 3, pp. 397-402.
76. Baron, R.M. and Kenny, D.A. (1986), "The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations", Journal of Personality and Social Psychology, Vol. 51 No. 6, pp. 1173-82.
77. Beer, M. (2003), "Why total quality management programs do not persist: the role of management quality and implications for leading a TQM transformation", Decision Sciences, Vol. 34 No. 4, pp. 623-42.
78. Detert, J.R., Schroeder, R.G. and Mauriel, J.J. (2000), "A framework for linking culture and improvement initiatives in organizations", Academy of Management Review, Vol. 25 No. 4, pp. 850-63.
79. Firth-Cozens, J. (2004), "Organizational trust: the keystone to patient safety", Quality & Safety in Health Care, Vol. 13, pp. 56-61.
80. Greene, J. (1999), "From whodunit to what happened", Hospitals & Health Networks, April, pp. 50-4.
81. Kujala, J. and Lillrank, P. (2004), "Total quality management as a cultural phenomenon", Quality Management Journal, Vol. 11 No. 4, pp. 43-55.
82. Leape, L.L., Bates, D.W., Cullen, D.J., Cooper, J., Demonaco, H.J., Gallivan, R., Hallisey, R., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Petersen, L.A., Porter, K., Li, L. and Benton, W.C. (2003), "Hospital capacity management decisions: emphasis on cost control and quality enhancement", European Journal of Operational Research, Vol. 146 No. 3, pp. 596-614.
83. McNabb, D.E. and Sepic, F.T. (1995), "Culture, climate, and total quality management: measuring readiness for change", Public Productivity & Management Review, Vol. 18 No. 4, pp. 369-85.
84. Servi, D., Shea, B.F., Small, S.D., Sweitzer, B.J., Thompson, B.T. and Vliet, M.V. (1995), "Systems analysis of adverse events", Journal of the American Medical Association, Vol. 274 No. 1, pp. 35-43.
85. Stevens, J. (1992), Applied Multivariate Statistics for the Social Sciences, Lawrence Erlbaum Associates, Hillsdale, NJ.
86. Wilson, D. (1998), "Where we've been... where we're going", The Flight Deck, January (February), pp. 6-8.