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Volumn 22, Issue 5, 2007, Pages 311-318

The role for leaders of health care organizations in patient safety

Author keywords

Adverse event; At risk behavior; Benchmark; Clinical pathway; Culture of safety; Disclosure of medical error; Error reporting; Failure mode and effect analysis; Health care leadership; High reliability organization; Medical error; Near miss; Patient safety

Indexed keywords

ARTICLE; HEALTH CARE FACILITY; HEALTH CARE QUALITY; HUMAN; INTERPERSONAL COMMUNICATION; LEADERSHIP; MEDICAL ERROR; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PERSONNEL MANAGEMENT; PROFESSIONAL STANDARD; SAFETY;

EID: 34548361702     PISSN: 10628606     EISSN: 1555824X     Source Type: Journal    
DOI: 10.1177/1062860607304743     Document Type: Article
Times cited : (52)

References (73)
  • 4
    • 34548328183 scopus 로고    scopus 로고
    • State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives. Portland, ME: National Academy for State
    • Rosenthal J., Booth M, Flowers L, Riley T. Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives. Portland, ME: National Academy for State Health Policy ; 2001.
    • (2001) Health Policy
    • Rosenthal, J.1
  • 5
    • 34548340625 scopus 로고    scopus 로고
    • Maximizing the Use of State Adverse Event Data to Improve Patient Safety. Portland, ME: National Academy for State
    • Rosenthal J., Booth M. Maximizing the Use of State Adverse Event Data to Improve Patient Safety. Portland, ME: National Academy for State Health Policy ; 2005.
    • (2005) Health Policy
    • Rosenthal, J.1    Booth, M.2
  • 6
    • 34548352787 scopus 로고    scopus 로고
    • Washington, DC: Medicare Payment Advisory Commission;
    • Medicare Payment Advisory Commission (MEDPAC). Report to the Congress: New Approaches in Medicare. Washington, DC: Medicare Payment Advisory Commission ; 2004: 147.
    • (2004) Report to the Congress: New Approaches in Medicare , pp. 147
  • 8
    • 34548342841 scopus 로고    scopus 로고
    • HealthGrades Quality Study: Second Annual Patient Safety in American Hospitals Report
    • Golden, CO: Grades;
    • HealthGrades Quality Study: Second Annual Patient Safety in American Hospitals Report. Golden, CO: Health Grades ; 2005.
    • (2005) Health
  • 9
    • 33646797002 scopus 로고    scopus 로고
    • Patient safety and quality improvement act of 2005
    • Fassett WE Patient safety and quality improvement act of 2005. Ann Pharmacother. 2006 ; 40: 917-924.
    • (2006) Ann Pharmacother. , vol.40 , pp. 917-924
    • Fassett, W.E.1
  • 10
    • 0034681819 scopus 로고    scopus 로고
    • Human error: Models and management
    • Reason J. Human error: models and management. Br Med J. 2000 ; 320: 768-770.
    • (2000) Br Med J. , vol.320 , pp. 768-770
    • Reason, J.1
  • 13
    • 0032752082 scopus 로고    scopus 로고
    • Organizing to reduce the vulnerabilities of complexity
    • Perrow C. Organizing to reduce the vulnerabilities of complexity. J Contingencies Crisis Manage. 1999 ; 7: 150-155.
    • (1999) J Contingencies Crisis Manage. , vol.7 , pp. 150-155
    • Perrow, C.1
  • 17
    • 0035885159 scopus 로고    scopus 로고
    • Complexity science: The challenge of complexity in health care
    • Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. Br Med J. 2001 ; 323: 625-628.
    • (2001) Br Med J. , vol.323 , pp. 625-628
    • Plsek, P.E.1    Greenhalgh, T.2
  • 18
    • 0035934650 scopus 로고    scopus 로고
    • Complexity and clinical care [erratum in: BMJ. 2001;323:993]
    • Wilson T., Holt T., Greenhalgh T. Complexity and clinical care [erratum in: BMJ. 2001;323:993]. Br Med J. 2001 ; 323: 685-688.
    • (2001) Br Med J. , vol.323 , pp. 685-688
    • Wilson, T.1    Holt, T.2    Greenhalgh, T.3
  • 19
    • 0035968621 scopus 로고    scopus 로고
    • Complexity, leadership, and management in healthcare organisations
    • Plsek P., Wilson T. Complexity, leadership, and management in healthcare organisations. Br Med J. 2001 ; 323: 746-749.
    • (2001) Br Med J. , vol.323 , pp. 746-749
    • Plsek, P.1    Wilson, T.2
  • 20
    • 0035818380 scopus 로고    scopus 로고
    • Coping with complexity: Educating for capability
    • Fraser SW, Greenhalgh T. Coping with complexity: educating for capability. Br Med J. 2001 ; 323: 799-803.
    • (2001) Br Med J. , vol.323 , pp. 799-803
    • Fraser, S.W.1    Greenhalgh, T.2
  • 21
    • 12444267092 scopus 로고    scopus 로고
    • Patient safety as an organizational systems issue: Lessons from a variety of industries
    • Youngberg BJ, Hatlie MJ, eds. Sudbury, MA: Jones & Bartlett ;
    • Roberts KH, Yu K., Van Stralen D. Patient safety as an organizational systems issue: lessons from a variety of industries. In: Youngberg BJ, Hatlie MJ, eds. The Patient Safety Handbook. Sudbury, MA: Jones & Bartlett ; 2004: 169-186.
    • (2004) The Patient Safety Handbook , pp. 169-186
    • Roberts, K.H.1    Yu, K.2    Van Stralen, D.3
  • 23
    • 6344229692 scopus 로고    scopus 로고
    • The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf
    • Leonard M., Graham S., Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 ; 13 (suppl 1). 85-90.
    • (2004) Health Care , vol.13 , Issue.1 , pp. 85-90
    • Leonard, M.1    Graham, S.2    Bonacum, D.3
  • 24
    • 33748693969 scopus 로고    scopus 로고
    • SBAR: A shared mental model for improving communication between clinicians
    • Haig KM, Sutton S., Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006 ; 32: 167-175.
    • (2006) Jt Comm J Qual Patient Saf , vol.32 , pp. 167-175
    • Haig, K.M.1    Sutton, S.2    Whittington, J.3
  • 25
    • 0035236282 scopus 로고    scopus 로고
    • Making health care safer: A critical analysis of patient safety practices
    • Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001 ; i-x: 1-688.
    • (2001) Evid Rep Technol Assess (Summ). , vol.1-10 , pp. 1-688
    • Shojania, K.G.1    Duncan, B.W.2    McDonald, K.M.3
  • 26
    • 33644857159 scopus 로고    scopus 로고
    • Forum 30 safe practices: Priority and progress in Iowa hospitals
    • Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in Iowa hospitals. Am J Med Qual. 2006 ; 21: 101-108.
    • (2006) Am J Med Qual. , vol.21 , pp. 101-108
    • Ward, M.M.1    Evans, T.C.2    Spies, A.J.3    Quality, N.4
  • 27
    • 0037164054 scopus 로고    scopus 로고
    • Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction
    • Aiken LH, Clarke SP, Sloane DM, Sochalski J., Silber JH Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 ; 288: 1987-1993.
    • (2002) JAMA. , vol.288 , pp. 1987-1993
    • Aiken, L.H.1    Clarke, S.P.2    Sloane, D.M.3    Sochalski, J.4    Silber, J.H.5
  • 29
    • 32044463181 scopus 로고    scopus 로고
    • Nurse staffing in hospitals: Is there a business case for quality?
    • Needleman J., Buerhaus PI, Stewart M., et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006 ; 25: 204-211.
    • (2006) Health Aff (Millwood) , vol.25 , pp. 204-211
    • Needleman, J.1    Buerhaus, P.I.2    Stewart, M.3
  • 30
    • 0037663736 scopus 로고    scopus 로고
    • Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review
    • Kaushal R., Shojania KG, Bates DW Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003 ; 163: 1409-1416.
    • (2003) Arch Intern Med. , vol.163 , pp. 1409-1416
    • Kaushal, R.1    Shojania, K.G.2    Bates, D.W.3
  • 31
    • 0038482036 scopus 로고    scopus 로고
    • Computer physician order entry: Benefits, costs, and issues
    • Kuperman GJ, Gibson RF Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003 ; 139: 31-39.
    • (2003) Ann Intern Med. , vol.139 , pp. 31-39
    • Kuperman, G.J.1    Gibson, R.F.2
  • 32
    • 33646121208 scopus 로고    scopus 로고
    • Return on investment for a computerized physician order entry system
    • Kaushal R., Jha AK, Franz C., et al. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006 ; 13: 261-266.
    • (2006) J Am Med Inform Assoc , vol.13 , pp. 261-266
    • Kaushal, R.1    Jha, A.K.2    Franz, C.3
  • 33
    • 0035038552 scopus 로고    scopus 로고
    • Outpatient laparoscopic cholecystectomy: Patient outcomes after implementation of a clinical pathway
    • Calland JF, Tanaka K., Foley E., et al. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg. 2001 ; 233: 704-715.
    • (2001) Ann Surg. , vol.233 , pp. 704-715
    • Calland, J.F.1    Tanaka, K.2    Foley, E.3
  • 34
    • 0037351660 scopus 로고    scopus 로고
    • Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection
    • Stephen AE, Berger DL Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003 ; 133: 277-282.
    • (2003) Surgery , vol.133 , pp. 277-282
    • Stephen, A.E.1    Berger, D.L.2
  • 35
    • 85009661516 scopus 로고    scopus 로고
    • Quality improvement and proactive hazard analysis models: Deciphering a new Tower of Babel
    • Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Washington, DC: National Academies Press;
    • McDonough JE, Solomon R., Petosa L. Quality improvement and proactive hazard analysis models: deciphering a new Tower of Babel. In: Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard of Care. Washington, DC: National Academies Press ; 2004: 471-508.
    • (2004) Patient Safety: Achieving A New Standard of Care , pp. 471-508
    • McDonough, J.E.1    Solomon, R.2    Petosa, L.3
  • 36
    • 0041814984 scopus 로고    scopus 로고
    • Proactive Hazard Analysis and Health Care Policy
    • New York:
    • McDonough JE Proactive Hazard Analysis and Health Care Policy. New York: Milbank Memorial Fund ; 2002.
    • (2002) Milbank Memorial Fund
    • McDonough, J.E.1
  • 37
    • 0035486819 scopus 로고    scopus 로고
    • Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
    • Bagian JP, Lee C., Gosbee J., et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001 ; 27: 522-532.
    • (2001) Jt Comm J Qual Improv , vol.27 , pp. 522-532
    • Bagian, J.P.1    Lee, C.2    Gosbee, J.3
  • 39
    • 28944453114 scopus 로고    scopus 로고
    • Mandatory state-based error-reporting systems: Current and future prospects
    • Wood KE, Nash DB Mandatory state-based error-reporting systems: current and future prospects. Am J Med Qual. 2005 ; 20: 297-303.
    • (2005) Am J Med Qual. , vol.20 , pp. 297-303
    • Wood, K.E.1    Nash, D.B.2
  • 41
  • 42
    • 33845452417 scopus 로고    scopus 로고
    • Translating patient safety legislation into health care practice
    • Rabinowitz Abk, Clarke, JR, Marella W., et al. Translating patient safety legislation into health care practice. Jt Comm J Qual Patient Saf. 2006 ; 32: 676-681.
    • (2006) Jt Comm J Qual Patient Saf. , vol.32 , pp. 676-681
    • Abk, R.1    Clarke, J.R.2    Marella, W.3
  • 43
    • 34548346789 scopus 로고    scopus 로고
    • Case study: NASA/VA patient safety reporting system
    • 2006
    • McCarthy D. Case study: NASA/VA patient safety reporting system. Commonwealth Fund Quality Matters Newsletter, 2004. Available at: http://www.cmwf.org/publications/publications_show.htm?doc_id=245255. Accessed August 14, 2006.
    • (2004) Commonwealth Fund Quality Matters Newsletter
    • McCarthy, D.1
  • 44
    • 0033814423 scopus 로고    scopus 로고
    • Human error in hospitals and industrial accidents: Current concepts
    • Spencer FC Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg. 2000 ; 191: 410-418.
    • (2000) J Am Coll Surg. , vol.191 , pp. 410-418
    • Spencer, F.C.1
  • 45
    • 3843110096 scopus 로고    scopus 로고
    • Communicating with patients about medical errors: A review of the literature
    • Mazor KM, Simon SR, Gurwitz JH Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004 ; 164: 1690-1697.
    • (2004) Arch Intern Med. , vol.164 , pp. 1690-1697
    • Mazor, K.M.1    Simon, S.R.2    Gurwitz, J.H.3
  • 46
    • 0036884176 scopus 로고    scopus 로고
    • Eisenberg Patient Safety Awards: Advocacy: the Lexington Veterans Affairs Medical Center
    • Kraman SS, Cranfill L., Hamm G., Woodard T., John M. Eisenberg Patient Safety Awards: Advocacy: the Lexington Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002 ; 28: 646-650.
    • (2002) Jt Comm J Qual Improv. , vol.28 , pp. 646-650
    • Kraman, S.S.1    Cranfill, L.2    Hamm, G.3    Woodard, T.4    John, M.5
  • 47
    • 33644678974 scopus 로고    scopus 로고
    • Patient preferences for error disclosure, reporting, and legal action after medical error in the care of their children
    • Hobgood C., Tamayo-Sarver JH, Elms A., Weiner B. Patient preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005 ; 116: 1276-1286.
    • (2005) Pediatrics , vol.116 , pp. 1276-1286
    • Hobgood, C.1    Tamayo-Sarver, J.H.2    Elms, A.3    Weiner, B.4
  • 48
    • 1542328163 scopus 로고    scopus 로고
    • Health plan members' views about disclosure of medical errors
    • Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med. 2004 ; 140: 409-418.
    • (2004) Ann Intern Med. , vol.140 , pp. 409-418
    • Mazor, K.M.1    Simon, S.R.2    Yood, R.A.3
  • 49
    • 34548368477 scopus 로고    scopus 로고
    • Curing the malpractice crisis
    • Boothman RC Curing the malpractice crisis. Surgical News. Aug 2006 ; 12.
    • (2006) Surgical News , vol.12
    • Boothman, R.C.1
  • 53
    • 0004001942 scopus 로고    scopus 로고
    • National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP taxonomy of medical errors, 1998. Available at: http://www.nccmerp.org/pdf/tax02001-07-31.pdf. Accessed April 23, 2007.
    • (2007) NCC MERP Taxonomy of Medical Errors, 1998
  • 58
    • 0031767967 scopus 로고    scopus 로고
    • Identification and classification of the causes of events in transfusion medicine
    • Kaplan HS, Battles JB, Van der Schaaf TW, et al. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998 ; 38: 1071-1081.
    • (1998) Transfusion. , vol.38 , pp. 1071-1081
    • Kaplan, H.S.1    Battles, J.B.2    Van Der Schaaf, T.W.3
  • 59
    • 34547503984 scopus 로고    scopus 로고
    • How a system for reporting medical errors can and cannot improve patient safety
    • Clarke JR How a system for reporting medical errors can and cannot improve patient safety. Am Surg. 2006: 72: 1088-1091.
    • (2006) Am Surg. , vol.72 , pp. 1088-1091
    • Clarke, J.R.1
  • 60
    • 34548342840 scopus 로고    scopus 로고
    • Pennsylvania Patient Safety Reporting System (PA-PSRS) Patient Safety Advisories. Available at: http://www.psa.state.pa.us/psa/cwp/view.asp?a= 1293&q=447107&psaNav=|. Accessed August 14, 2006.
    • (2006) Patient Safety Advisories
  • 61
    • 34548370612 scopus 로고    scopus 로고
    • New Jersey Department of Health and Senior Services Patient Safety Initiatives. Available at: http://www.state.nj.us/health/hcqo/ps/newsletter. shtml. Accessed August 14, 2006.
    • (2006)
  • 62
    • 28844491799 scopus 로고    scopus 로고
    • Health care provider use of private sector internal error-reporting systems
    • Roumm AR, Sciamanna CN, Nash DB Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005 ; 20: 304-312.
    • (2005) Am J Med Qual. , vol.20 , pp. 304-312
    • Roumm, A.R.1    Sciamanna, C.N.2    Nash, D.B.3
  • 63
    • 28944433025 scopus 로고    scopus 로고
    • The long road to patient safety: A status report on patient safety systems
    • Longo DR, Hewett JE, Ge B., Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA. 2005 ; 294: 2858-2865.
    • (2005) JAMA. , vol.294 , pp. 2858-2865
    • Longo, D.R.1    Hewett, J.E.2    Ge, B.3    Schubert, S.4
  • 65
    • 0348216532 scopus 로고    scopus 로고
    • Safety culture assessment: A tool for improving patient safety in healthcare organizations. Quality Saf
    • Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Quality Saf Health Care. 2003 ; 12 (suppl 2). 17-23.
    • (2003) Health Care , vol.12 , Issue.2 , pp. 17-23
    • Nieva, V.F.1    Sorra, J.2
  • 66
    • 33745611771 scopus 로고    scopus 로고
    • How will we know patients are safer? An organization-wide approach to measuring and improving safety
    • Pronovost P., Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med. 2006 ; 34: 1988-1995.
    • (2006) Crit Care Med. , vol.34 , pp. 1988-1995
    • Pronovost, P.1    Holzmueller, C.G.2    Needham, D.M.3
  • 68
    • 84996605942 scopus 로고    scopus 로고
    • Boss buy-in: One of the least expensive tools to enhance safety
    • Dickey NW Boss buy-in: one of the least expensive tools to enhance safety. J Patient Saf. 2005 ; 1: 123.
    • (2005) J Patient Saf. , vol.1 , pp. 123
    • Dickey, N.W.1
  • 69
    • 33748333207 scopus 로고    scopus 로고
    • Engagement of leadership in quality improvement initiatives: Executive quality improvement survey results
    • Vaughn T., Koepke M., Kroch E., et al. Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. J Patient Saf. 2006 ; 2: 2-9.
    • (2006) J Patient Saf. , vol.2 , pp. 2-9
    • Vaughn, T.1    Koepke, M.2    Kroch, E.3
  • 70
    • 34548352786 scopus 로고    scopus 로고
    • Self-assessment questionnaire 30: Patient safety
    • Plymouth Meeting, PA: ECRI;
    • ECRI Institute. Self-assessment questionnaire 30: patient safety. In: Healthcare Risk Control. Vol 1. Plymouth Meeting, PA: ECRI ; 2005: 1-13.
    • (2005) Healthcare Risk Control , pp. 1-13
    • Institute, E.1
  • 71
    • 33748121064 scopus 로고    scopus 로고
    • Getting the board on board: Engaging hospital boards in quality and patient safety
    • Joshi MS, Hines SC Getting the board on board: engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006 ; 32: 179-187.
    • (2006) Jt Comm J Qual Patient Saf. , vol.32 , pp. 179-187
    • Joshi, M.S.1    Hines, S.C.2
  • 72
    • 33745818567 scopus 로고    scopus 로고
    • Size, composition, and culture of high-performing hospital boards
    • Prybil LD Size, composition, and culture of high-performing hospital boards. Am J Med Qual. 2006 ; 21: 224-229.
    • (2006) Am J Med Qual. , vol.21 , pp. 224-229
    • Prybil, L.D.1
  • 73
    • 33646078911 scopus 로고    scopus 로고
    • Norms Group. Enhancing the use of clinical guidelines: A social norms perspective
    • McDonnell Norms Group. Enhancing the use of clinical guidelines: a social norms perspective. J Am Coll Surg. 2006 ; 202: 826-836.
    • (2006) J Am Coll Surg. , vol.202 , pp. 826-836
    • McDonnell1


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