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Volumn 8, Issue 1, 2012, Pages 3-14

An NTSB for health care - Learning from innovation: Debate and innovate or capitulate

Author keywords

accidents; communications; IT and safety; product technology development and adoption; quality; reporting systems; risk assessment system organizational failure

Indexed keywords

AIRCRAFT ACCIDENT; ARTICLE; EVIDENCE BASED PRACTICE; GOVERNMENT; HEALTH CARE DELIVERY; MASS COMMUNICATION; MEDICAL ERROR; PATIENT SAFETY; RISK ASSESSMENT; TECHNOLOGY; UNITED STATES;

EID: 84857847965     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0b013e3182446c51     Document Type: Article
Times cited : (28)

References (85)
  • 1
    • 84857818606 scopus 로고    scopus 로고
    • What Could You Do with a Projected U.S. Debt of $15 Trillion? ABC News [Web site]. February 14 2011. Available at. Accessed October 16, 2011
    • Kim S. What Could You Do with a Projected U.S. Debt of $15 Trillion? ABC News [Web site]. February 14, 2011. Available at: Http:// abcnews.go.com/Business/us-national-debt-reach-15-trillion-year-48000/ story?id=12915280. Accessed October 16, 2011.
    • Kim, S.1
  • 2
  • 3
    • 84857888615 scopus 로고    scopus 로고
    • Storms on the Horizon. Remarks before the Commonwealth Club of California. May 28, 2008. Federal Reserve Bank of Dallas Web site. Available at Accessed November 14, 2011
    • Fisher RW. Storms on the Horizon. Remarks before the Commonwealth Club of California. May 28, 2008. Federal Reserve Bank of Dallas Web site. Available at: Http://www.dallasfed.org/news/ speeches/fisher/2008/fs080528.cfm. Accessed November 14, 2011.
    • Fisher, R.W.1
  • 4
    • 84857806134 scopus 로고    scopus 로고
    • 18 Scary US Debt Facts. CBS Money Watch.com [Web site]. Updated July 13 2011. Available at. Accessed October 17, 2011
    • Schlesinger J. 18 Scary US Debt Facts. CBS Money Watch.com [Web site]. Updated July 13, 2011. Available at: Http:// moneywatch.bnet.com/economic-news/ blog/financial-decoder/ 18-scary-us-debt-facts/2824/. Accessed October 17, 2011.
    • Schlesinger, J.1
  • 5
    • 84857858839 scopus 로고    scopus 로고
    • Milliman Consulting. 2011 Milliman Medical Index. Healthcare costs for American families double in less than nine years. Milliman Research Report. May 2011. Available at, Accessed October 12, 2011
    • Milliman Consulting. 2011 Milliman Medical Index. Healthcare costs for American families double in less than nine years. Milliman Research Report. May 2011. Available at: Http://publications.milliman.com/ periodicals/mmi/pdfs/ milliman-medical-index-2011.pdf. Accessed October 12, 2011.
  • 6
    • 84857818611 scopus 로고    scopus 로고
    • PwC. The price of excess: Identifying waste in healthcare spending. Delaware. PricewaterhouseCoopers'Health Research Institute. 2010. Available at,: Accessed October 13, 2011
    • PwC. The price of excess: Identifying waste in healthcare spending. Delaware. PricewaterhouseCoopers'Health Research Institute. 2010. Available at: Http://www.pwc.com/us/en/healthcare/ publications/the-price-of-excess.jhtml. Accessed October 13, 2011.
  • 7
    • 81855169086 scopus 로고    scopus 로고
    • A decade of health care cost growth has wiped out real income gains for an average US family
    • Auerbach DI, Kellermann AL. A decade of health care cost growth has wiped out real income gains for an average US family. Health Aff (Millwood). 2011;30:1630-1636.
    • (2011) Health Aff (Millwood). , vol.30 , pp. 1630-1636
    • Auerbach, D.I.1    Kellermann, A.L.2
  • 8
    • 84857818609 scopus 로고    scopus 로고
    • WHO. World Health Statistics 2011. Geneva, Switzerland: World Health Organization, 2011. Available at. Accessed October 13, 2011
    • WHO. World Health Statistics 2011. Geneva, Switzerland: World Health Organization, 2011. Available at: Http://www.who.int/whosis/whostat/EN-WHS2011- Full.pdf. Accessed October 13, 2011.
  • 9
    • 84857818610 scopus 로고    scopus 로고
    • SafetyLeaders. Chasing Zero: Winning the War on Healthcare Harm. Hospital Leaders Toolbox. ND. Available at: Accessed October 13, 2011
    • SafetyLeaders. Chasing Zero: Winning the War on Healthcare Harm. Hospital Leaders Toolbox. ND. Available at: Http://www.safetyleaders. org/leadersToolbox/home.jsp. Accessed October 13, 2011.
  • 10
    • 84857888616 scopus 로고    scopus 로고
    • Chasing Zero: Winning the War on Healthcare Harm [video]. Austin TX: TMIT; 2010. Available at. Accessed September 27, 2011
    • Chasing Zero: Winning the War on Healthcare Harm [video]. Austin, TX: TMIT; 2010. Available at: Http://www.safetyleaders.org/pages/ chasingZeroDocumentary.jsp. Accessed September 27, 2011.
  • 12
    • 84857818612 scopus 로고    scopus 로고
    • Jet Pilot. Movie. 1957. Available at, Accessed November 11, 2011
    • Jet Pilot. Movie. 1957. Available at: Http://www.imdb.com/title/ tt0050562/. Accessed November 11, 2011.
  • 14
    • 84857806126 scopus 로고    scopus 로고
    • Sony Pictures Classics. Inside Job [video]. 2010. Available at: Accessed October 12, 2011
    • Sony Pictures Classics. Inside Job [video]. 2010. Available at: Http:// www.amazon.com/Inside-Job-Matt-Damon/dp/B0041KKYBA/ref=sr-1-1?s= movies-tv&ie=UTF8&qid=1318202508&sr=1-1. Accessed October 12, 2011.
  • 15
    • 84857858840 scopus 로고    scopus 로고
    • HBO. Too Big to Fail [video]. 2011. Available at. Accessed October 7, 2011
    • HBO. Too Big to Fail [video]. 2011. Available at: Http://www.hbo.com/ movies/too-big-to-fail/index.html. Accessed October 7, 2011.
  • 19
    • 84857876431 scopus 로고    scopus 로고
    • Holy Bible
    • (KJV
    • Holy Bible. Hebrews 11:1 (KJV).
    • Hebrews , vol.11 , pp. 1
  • 20
    • 84857806127 scopus 로고    scopus 로고
    • Holy Bible
    • (KJV
    • Holy Bible. II Timothy 1:7 (KJV).
    • II Timothy , vol.1 , pp. 7
  • 22
    • 84857806124 scopus 로고    scopus 로고
    • NTSB. Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River: US Airways Flight 1549, Airbus A320-214, N106US. Weehawken, New Jersey. January 15, 2009. Accident Report. NTSB/AAR-10/03. PB2010-910403. Washington, DC: National Transportation Safety Board, 2010. Available at: Accessed October 14, 2011
    • NTSB. Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River: US Airways Flight 1549, Airbus A320-214, N106US. Weehawken, New Jersey. January 15, 2009. Accident Report. NTSB/AAR-10/03. PB2010-910403. Washington, DC: National Transportation Safety Board, 2010. Available at: Www.ntsb.gov/doclib/reports/2010/ AAR1003.pdf. Accessed October 14, 2011.
  • 23
    • 67651065571 scopus 로고    scopus 로고
    • May I have the envelope please?
    • Denham CR. May I have the envelope please? J Patient Saf. 2008;4:119-223.
    • (2008) J Patient Saf. , vol.4 , pp. 119-223
    • Denham, C.R.1
  • 25
    • 84857806125 scopus 로고    scopus 로고
    • AARP. A Medical Mistake nearly killed his infant twinsVand inspired a personal mission to save lives [video]. July 22, 2010. AARP The Magazine. Available at. Accessed October 13, 2011
    • AARP. A Medical Mistake nearly killed his infant twinsVand inspired a personal mission to save lives [video]. July 22, 2010. AARP The Magazine. Available at: Http://www.aarp.org/entertainment/ movies-tv/info-07-2010/dennis- quaid-video.html. Accessed October 13, 2011.
  • 26
    • 84857818614 scopus 로고    scopus 로고
    • Your Weekly Inspiration [newsletter]. Danbury CT: Guideposts, Available at: Accessed October 14, 2011
    • Quaid D. A Father's Prayer. Your Weekly Inspiration [newsletter]. Danbury, CT: Guideposts, 2011. Available at: Http://broadcaster. guideposts.org/dm?id=86A82BB9F09E22D70A6A7A381C12D423. Accessed October 14, 2011.
    • (2011) A Father's Prayer
    • Quaid, D.1
  • 30
    • 84857806128 scopus 로고    scopus 로고
    • WHO. Surgical Safety Checklist (First Edition). Geneva Switzerland: World Health Organization, 2008. Available at, Accessed October 13, 2011
    • WHO. Surgical Safety Checklist (First Edition). Geneva, Switzerland: World Health Organization, 2008. Available at: Http://www.who.int/patientsafety/ safesurgery/tools-resources/SSSL-Checklist-finalJun08.pdf. Accessed October 13, 2011.
  • 31
    • 84857888617 scopus 로고    scopus 로고
    • Greenlight Program. Texas Medical Institute of Technology. ND. Available at.Accessed October 10, 2011
    • Greenlight Program. Texas Medical Institute of Technology. ND. Available at: Http://www.safetyleaders.org/greenlight/. Accessed October 10, 2011.
  • 32
    • 84857818613 scopus 로고    scopus 로고
    • AHRQ. TeamSTEPPS Program. ND. Agency for Healthcare Research and Quality. Available at: Accessed October 10, 2011
    • AHRQ. TeamSTEPPS Program. ND. Agency for Healthcare Research and Quality. Available at: Http://teamstepps.ahrq.gov/. Accessed October 10, 2011.
  • 33
    • 77958048000 scopus 로고    scopus 로고
    • Mixed results in the safety performance of computerized physician order entry
    • Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician order entry. Health Aff (Millwood). 2010;29:655-663.
    • (2010) Health Aff (Millwood). , vol.29 , pp. 655-663
    • Metzger, J.1    Welebob, E.2    Bates, D.W.3
  • 34
    • 77949471319 scopus 로고    scopus 로고
    • National Quality Forum (NQF). Safe Practice 16: Safe Adoption of Computerized Prescriber Order Entry. In. Washington, DC: National Quality Forum
    • National Quality Forum (NQF). Safe Practice 16: Safe Adoption of Computerized Prescriber Order Entry. In: Safe Practices for Better HealthcareV2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010:207-213.
    • (2010) Safe Practices for Better HealthcareV2010 Update: A Consensus Report , pp. 207-213
  • 35
    • 33845443765 scopus 로고    scopus 로고
    • The National Quality Forum Safe Practice Standard for computerized physician order entry: Updating a critical patient safety practice
    • Kilbridge PM, Classen D, Bates DW, et al. The National Quality Forum Safe Practice Standard for computerized physician order entry: Updating a critical patient safety practice. J Patient Saf. 2006;2:183-190.
    • (2006) J Patient Saf. , vol.2 , pp. 183-190
    • Kilbridge, P.M.1    Classen, D.2    Bates, D.W.3
  • 36
    • 79958044386 scopus 로고    scopus 로고
    • Critical drug-drug interactions for use in electronic health records systems with computerized physician order entry: Review of leading approaches
    • Classen DC, Phansalkar S, Bates DW. Critical drug-drug interactions for use in electronic health records systems with computerized physician order entry: Review of leading approaches. J Patient Saf. 2011;7:61-65.
    • (2011) J Patient Saf. , vol.7 , pp. 61-65
    • Classen, D.C.1    Phansalkar, S.2    Bates, D.W.3
  • 37
    • 77949430220 scopus 로고    scopus 로고
    • Meaningful use of computerized prescriber order entry
    • Classen D, Bates DW, Denham CR. Meaningful use of computerized prescriber order entry. J Patient Saf. 2010;6:15-23.
    • (2010) J Patient Saf. , vol.6 , pp. 15-23
    • Classen, D.1    Bates, D.W.2    Denham, C.R.3
  • 38
    • 84857818615 scopus 로고    scopus 로고
    • AARP the Magazine 2010 Sept/Oct;48-51 90-1. Available at. Accessed October 12, 2011
    • Grant M. Dennis Quaid Wants to Save Your Life. AARP the Magazine 2010 Sept/Oct;48-51, 90-1. Available at: Http:// www.safetyleaders.org/downloads/ AARP-July2010-Quaid.pdf. Accessed October 12, 2011.
    • Dennis Quaid Wants to Save Your Life
    • Grant, M.1
  • 39
    • 84857818616 scopus 로고    scopus 로고
    • Partnership for Patients. ND. Available at. Accessed November 8, 2011
    • Partnership for Patients. ND. Available at: Http://www.healthcare.gov/ compare/partnership-for-patients/. Accessed November 8, 2011.
  • 40
    • 84857857265 scopus 로고    scopus 로고
    • Online Press Release. June 13 2011. Available at. Accessed October 17
    • Reese E. NQF Releases Updated Serious Reportable Events. Online Press Release. June 13, 2011. Available at: Http://www.qualityforum.org/News-And- Resources/Press-Releases/2011/NQF-Releases-Updated-Serious-Reportable-Events. aspx. Accessed October 17, 2011.
    • (2011) NQF Releases Updated Serious Reportable Events
    • Reese, E.1
  • 41
    • 84857858842 scopus 로고    scopus 로고
    • NQF. Serious Reportable Events in Healthcare 2006 Update.Washington, DC: National Quality Forum, 2007. Available at. Accessed October 14, 2011
    • NQF. Serious Reportable Events in Healthcare 2006 Update.Washington, DC: National Quality Forum, 2007. Available at: Http:// www.qualityforum.org/ Publications/2007/03/Serious-Reportable-Events-in-Healthcare%E2%80%932006- Update.aspx. Accessed October 14, 2011.
  • 43
    • 84857806130 scopus 로고    scopus 로고
    • Texas Children's Hospital. The Simulation Center. Webpage. ND. Available at, Accessed November 14, 2011
    • Texas Children's Hospital. The Simulation Center. Webpage. ND. Available at: Http://www.einstein.edu/education/educational-resources/ simulation-center.html. Accessed November 14, 2011.
  • 44
    • 84857888619 scopus 로고    scopus 로고
    • US Dept. of Defense. Patient Safety Program. TeamSTEPPS webpage. ND. Available at, Accessed November 14, 2011
    • US Dept. of Defense. Patient Safety Program. TeamSTEPPS webpage. ND. Available at: Http://www.health.mil/dodpatientsafety/ ProductsandServices/ TeamSTEPPS.aspx. Accessed November 14, 2011.
  • 45
    • 77949478915 scopus 로고    scopus 로고
    • Green light issues for the CFO: Investing in patient safety
    • Denham CR. Green light issues for the CFO: Investing in patient safety. J Patient Saf. 2010;6:52-56.
    • (2010) J Patient Saf. , vol.6 , pp. 52-56
    • Denham, C.R.1
  • 46
    • 84857888620 scopus 로고    scopus 로고
    • Alliance for Radiation Safety in Pediatric Imaging. Image Gently Campaign [Alliance for Radiation Safety in Pediatric Imaging website]. ND. Available at. Accessed October 12, 2011
    • Alliance for Radiation Safety in Pediatric Imaging. Image Gently Campaign [Alliance for Radiation Safety in Pediatric Imaging website]. ND. Available at: Http://www.pedrad.org/associations/5364/ig/. Accessed October 12, 2011.
  • 47
    • 84857806129 scopus 로고    scopus 로고
    • CMS Hospital Value-Based Purchasing official Web site. ND. Available at. Accessed November 14, 2011
    • CMS Hospital Value-Based Purchasing official Web site. ND. Available at: Http://www.cms.gov/Hospital-Value-Based-Purchasing/. Accessed November 14, 2011.
  • 48
    • 84857888624 scopus 로고    scopus 로고
    • TMIT. SafetyleadersWeb site. ND. Available at: Accessed November 14, 2011
    • TMIT. SafetyleadersWeb site. ND. Available at: Www.safetyleaders.org. Accessed November 14, 2011.
  • 49
    • 84857888621 scopus 로고    scopus 로고
    • TMIT. LEAD Hospitals Initiatives: Leadership Engagement And Development [Web site]. Austin, TX: Texas Medical Institute of Technology, N.D. Available at. Accessed October 17, 2011
    • TMIT. LEAD Hospitals Initiatives: Leadership Engagement And Development [Web site]. Austin, TX: Texas Medical Institute of Technology, N.D. Available at: Http://www.safetyleaders.org/ lead/?step=7#tabs. Accessed October 17, 2011.
  • 50
    • 84857888622 scopus 로고    scopus 로고
    • SpeakerLink website. ND. Available at. Accessed November 14, 2011
    • SpeakerLink website. ND. Available at: Http://www.speakerlink.org/. Accessed November 14, 2011.
  • 51
    • 33645932905 scopus 로고    scopus 로고
    • Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems
    • Kilbridge PM, Welebob EM, Classen DC. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual Saf Health Care. 2006;15:81-84.
    • (2006) Qual Saf Health Care. , vol.15 , pp. 81-84
    • Kilbridge, P.M.1    Welebob, E.M.2    Classen, D.C.3
  • 53
    • 84857888623 scopus 로고    scopus 로고
    • Aviation Safety Reporting System [Web site]. N.D. Available at:. Accessed October 17, 2011
    • Aviation Safety Reporting System [Web site]. N.D. Available at: Http://asrs.arc.nasa.gov/overview/summary.html. Accessed October 17, 2011.
  • 54
    • 73949123382 scopus 로고    scopus 로고
    • Common formats allow uniform collection and reporting of patient safety data by patient safety organizations
    • Clancy CM. Common formats allow uniform collection and reporting of patient safety data by patient safety organizations. Am J Med Qual. 2010;25:73-75.
    • (2010) Am J Med Qual. , vol.25 , pp. 73-75
    • Clancy, C.M.1
  • 55
    • 84857818619 scopus 로고    scopus 로고
    • A Notice by the Agency for Healthcare Research and Quality. Washington, DC: Office of the Federal Register, October 22, 2010 FR Doc. 2010-26667. Available at. Accessed October 17
    • Clancy CM. Common Formats for Patient Safety Data Collection and Event Reporting. A Notice by the Agency for Healthcare Research and Quality. Washington, DC: Office of the Federal Register, October 22, 2010. FR Doc. 2010-26667. Available at: Http://www.federalregister.gov/articles/2010/10/22/ 2010-26667/ common-formats-for-patient-safety-data-collection-and-event- reporting. Accessed October 17, 2011.
    • (2011) Common Formats for Patient Safety Data Collection and Event Reporting
    • Clancy, C.M.1
  • 56
    • 84857858844 scopus 로고    scopus 로고
    • HHS. Patient Safety and Quality Improvement Act of 2005 Statute and Rule [Web site]. Washington, DC: U.S. Department of Health & Human Services, 2005. Available at. Accessed October 17, 2011
    • HHS. Patient Safety and Quality Improvement Act of 2005 Statute and Rule [Web site]. Washington, DC: U.S. Department of Health & Human Services, 2005. Available at: Http://www.hhs.gov/ocr/privacy/psa/ regulation/index.html. Accessed October 17, 2011.
  • 57
    • 84857858847 scopus 로고    scopus 로고
    • PSO PPC. Patient Safety Organization Privacy Protection Center [Web site]. Rockville MD: Agency for Healthcare Research and Quality (AHRQ), N.D. Available at: Accessed October 17, 2011
    • PSO PPC. Patient Safety Organization Privacy Protection Center [Web site]. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), N.D. Available at: Https://www.psoppc.org/web/patientsafety. Accessed October 17, 2011.
  • 58
    • 0002838425 scopus 로고    scopus 로고
    • Computerized physician order entry (CPOE) with clinical decision support systems (CDSSs
    • Evidence Report/Technology Assessment, No. 43. AHRQ Publication No. 01-E058. Ch. 6. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ), Jul. Available at, Accessed October 17, 2011
    • Kaushal R, Bates DW. Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSSs). IN: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43. AHRQ Publication No. 01-E058. Ch. 6. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ), 2001 Jul. Available at: Http://archive.ahrq.gov/ clinic/ptsafety/chap6.htm. Accessed October 17, 2011.
    • (2001) Making Health Care Safer: A Critical Analysis of Patient Safety Practices
    • Kaushal, R.1    Bates, D.W.2
  • 59
    • 33847658288 scopus 로고    scopus 로고
    • Clinical health information technologies and the role of Medicaid
    • Winter
    • Alfreds ST, Tutty M, Savageau JA, et al. Clinical health information technologies and the role of Medicaid. Health Care Financ Rev 2006 Winter;28(2):11-20.
    • (2006) Health Care Financ Rev , vol.28 , Issue.2 , pp. 11-20
    • Alfreds, S.T.1    Tutty, M.2    Savageau, J.A.3
  • 60
    • 65349170070 scopus 로고    scopus 로고
    • CPOE: It don't come easy
    • Jan, 22, 24 passim. Available at. Accessed October 17
    • Anderson HJ. CPOE: It Don't Come Easy. Health Data Manag 2009 Jan;17(1):18-20, 22, 24 passim. Available at: Http://www.healthdatamanagement. com/issues/2008-60/ 27494-1.html?zkPrintable=true. Accessed October 17, 2011.
    • (2009) Health Data Manag , vol.17 , Issue.1 , pp. 18-20
    • Anderson, H.J.1
  • 63
    • 75849118810 scopus 로고    scopus 로고
    • Safe electronic health record use requires a comprehensive monitoring and evaluation framework
    • Feb 3. Available at. Accessed October 17, 2011
    • Sittig DF, Classen DC. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA 2010 Feb 3;303(5):450-1. Available at:http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2965782/?tool=pubmed. Accessed October 17, 2011.
    • (2010) JAMA , vol.303 , Issue.5 , pp. 450-1
    • Sittig, D.F.1    Classen, D.C.2
  • 64
    • 0032556180 scopus 로고    scopus 로고
    • Effect of computerized physician order entry and a team intervention on prevention of serious medication errors
    • Oct 21; Available at. Accessed October 17 1998
    • Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998 Oct 21;280(15):1311-6. Available at: Http://jama.ama-assn.org/cgi/ pmidlookup?view=long&pmid=9794308. Accessed October 17, 2011.
    • (2011) JAMA , vol.280 , Issue.15 , pp. 1311-6
    • Bates, D.W.1    Leape, L.L.2    Cullen, D.J.3
  • 65
    • 84857858849 scopus 로고    scopus 로고
    • IOM. Health IT and Patient Safety. Building Safer Systems for Better Care. Washington, DC. Institute of Medicine of the National Academies. Nov. 2011. Report Brief available at: Accessed: November 8, 2011
    • IOM. Health IT and Patient Safety. Building Safer Systems for Better Care. Washington, DC. Institute of Medicine of the National Academies. Nov. 2011. Report Brief available at: Http://iom.edu/~/media/Files/Report%20Files/ 2011/Health-IT/ healthITbrief.pdf. Accessed: November 8, 2011.
  • 66
    • 81855227297 scopus 로고    scopus 로고
    • Creating an oversight infrastructure for electronic health record-related patient safety hazards
    • Singh H, Classen D, Sittig D. Creating an oversight infrastructure for electronic health record-related patient safety hazards. J Patient Saf. 2011;7:169-274.
    • (2011) J Patient Saf. , vol.7 , pp. 169-274
    • Singh, H.1    Classen, D.2    Sittig, D.3
  • 67
    • 84857806131 scopus 로고    scopus 로고
    • Danger Zone Documentary. HD Trailer. 2011. TMIT. Available at. Accessed November 11, 2011
    • Danger Zone Documentary. HD Trailer. 2011. TMIT. Available at: Http://www.safetyleaders.org/discovery/dangerZone.jsp. Accessed November 11, 2011.
  • 68
    • 80052262940 scopus 로고    scopus 로고
    • The partnership with patients: A call to action for leaders
    • Denham CR. The partnership with patients: A call to action for leaders. J Patient Saf. 2011;7:113-121.
    • (2011) J Patient Saf. , vol.7 , pp. 113-121
    • Denham, C.R.1
  • 69
    • 70449416400 scopus 로고    scopus 로고
    • Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases. Atlanta, GA: Centers for Disease Control and Prevention, Mar. Available at: Accessed October 17, 2011
    • Scott RD II. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases. Atlanta, GA: Centers for Disease Control and Prevention, 2009 Mar. Available at: Http://www.cdc.gov/ncidod/dhqp/pdf/Scott-CostPaper.pdf. Accessed October 17, 2011.
    • (2009) The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention
    • Scott II, R.D.1
  • 70
    • 84857858850 scopus 로고    scopus 로고
    • TMIT. Accelerating Healthcare-Associated Infection Elimination: Health System, Hospital, and Government Leadership Collaboration. Webinar presented by Texas Medical Institute of Technology (Austin, TX) at National Press Club (Washington, DC) on October 28, 2010. Available at. Accessed October 17, 2011
    • TMIT. Accelerating Healthcare-Associated Infection Elimination: Health System, Hospital, and Government Leadership Collaboration. Webinar presented by Texas Medical Institute of Technology (Austin, TX) at National Press Club (Washington, DC) on October 28, 2010. Available at: Http://www.safetyleaders. org/webinars/indexWebinar-October2010.jsp. Accessed October 17, 2011.
  • 71
    • 84857806132 scopus 로고    scopus 로고
    • C-SPAN. Dennis Quaid Remarks on Medical Errors. Washington, DC: National Press Club, April 12, 2010. Available at: Accessed October 17, 2011
    • C-SPAN. Dennis Quaid Remarks on Medical Errors. Washington, DC: National Press Club, April 12, 2010. Available at: Http:// www.c-spanvideo.org/program/ 292941-1. Accessed October 17, 2011.
  • 72
    • 84857818620 scopus 로고
    • Boeing. Accident prevention strategies: Removing links in the accident chain. Commercial jet aircraft accidents. Seattle, WA: Boeing Commercial Airplane Group
    • Boeing. Accident prevention strategies: Removing links in the accident chain. Commercial jet aircraft accidents. World wide operations 1982-1991. Seattle, WA: Boeing Commercial Airplane Group; 1993.
    • (1993) World Wide Operations 1982-1991
  • 73
    • 84857845143 scopus 로고
    • Aviation accident investigation and safety performance
    • Dubuque IA: Kendall Hunt Publishing Available at:. Accessed October 12, 2011
    • Kane RM. Aviation Accident Investigation and Safety Performance. In: Air Transportation. Dubuque, IA: Kendall Hunt Publishing, 1993:257-302. Available at: Http://books.google.com/books?id=nCFYdB2H05UC&pg=PA283&lpg= PA283&dq=Boeing+study+of+future+hull+losses&source=bl&ots= sxaDRVYWvc&sig=8iO4EVnduGj-ShOuMSF1e0n-11Y&hl=en&ei= 5J6LTrDFDaTpsQLT-d2VBA&sa=X&oi=book-result&ct=result&resnum= 4&ved=0CDcQ6AEwAw#v=onepage&q= Boeing%20study%20of%20future%20hull%20losses&f=false. Accessed October 12, 2011.
    • (1993) Air Transportation. , pp. 257-302
    • Kane, R.M.1
  • 74
    • 84857888626 scopus 로고    scopus 로고
    • CAST. The Commercial Aviation Safety Team [Web site]. Available at:. Accessed October 13, 2011
    • CAST. The Commercial Aviation Safety Team [Web site]. Available at: Http://www.cast-safety.org/about-background.cfm. Accessed October 13, 2011.
  • 75
    • 84857818623 scopus 로고    scopus 로고
    • First, make no mistakes
    • Hall J. First, make no mistakes. The New York Times. 2009;A23.
    • (2009) The New York Times. , vol.A23
    • Hall, J.1
  • 76
    • 84858204929 scopus 로고    scopus 로고
    • Stop coddling the super-Rich
    • August 14, 2011. Available at: Accessed November 14, 2011
    • Buffet, W. Stop Coddling the Super-Rich. New York Times. August 14, 2011. Available at: Http:// www.nytimes.com/2011/08/15/opinion/stop-coddling-the- super-rich.html?-r=1&scp=1&sq=buffett%20and%20taxes&st=cse. Accessed November 14, 2011.
    • New York Times
    • Buffet, W.1
  • 77
    • 84857858848 scopus 로고    scopus 로고
    • NTSB. History of the National Transportation Safety Board. ND. Available at: Accessed October 13, 2011
    • NTSB. History of the National Transportation Safety Board. ND. Available at: Http://www.ntsb.gov/about/history.html. Accessed October 13, 2011.
  • 78
    • 84857818622 scopus 로고    scopus 로고
    • ThinkExist. Robert Kennedy Quote. Online. ND. Available at: Accessed November 8, 2011
    • ThinkExist. Robert Kennedy Quote. Online. ND. Available at: Http://thinkexist.com/quotation/there-are-those-who-look-at-things-the-way-they/ 14583.html. Accessed November 8, 2011.
  • 79
    • 33746382618 scopus 로고    scopus 로고
    • Patient safety practices: Leaders can turn barriers into accelerators
    • Denham CR. Patient safety practices: Leaders can turn barriers into accelerators. J Patient Saf. 2005;1:41-55.
    • (2005) J Patient Saf. , vol.1 , pp. 41-55
    • Denham, C.R.1
  • 80
    • 36749102937 scopus 로고    scopus 로고
    • The no-outcome, no-income tsunami: Surviving "pay 4 performance". National Patient Safety Foundation newsletter
    • Denham CR. The no-outcome, no-income tsunami: Surviving "pay 4 performance". National Patient Safety Foundation newsletter. Focus Patient Saf. 2004;7:1-3.
    • (2004) Focus Patient Saf. , vol.7 , pp. 1-3
    • Denham, C.R.1
  • 81
    • 68349125710 scopus 로고    scopus 로고
    • The no outcome-no income tsunami is here: Are you a surfer, swimmer, or sinker?
    • Denham CR. The no outcome-no income tsunami is here: Are you a surfer, swimmer, or sinker? J Patient Saf. 2009;5:42-52.
    • (2009) J Patient Saf. , vol.5 , pp. 42-52
    • Denham, C.R.1


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.