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APPENDIX I

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Key Books and Reports on Medical Errors and Errors More Generally

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  1. Agency for Healthcare Research and Quality. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1–4).

  2. Agency for Healthcare Research and Quality. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1–4).

  3. Agency for Healthcare Research and Quality. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation. Rockville, MD: Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.

  4. Agency for Healthcare Research and Quality. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data from National Efforts to Make Health Care Safer. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

  5. American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare. Reducing the Risks of Wrong-Site Surgery: Safety Practices from the Joint Commission Center for Transforming Healthcare Project. Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.

  6. Antonsen S. Safety Culture: Theory, Method and Improvement. Burlington, VT: Ashgate; 2009.

  7. Berwick DM. Escape Fire: Designs for the Future of Health Care. San Francisco, CA: Jossey-Bass; 2003.

  8. Betsy Lehman Center for Patient Safety and Error Reduction. The Public's Views on Medical Error in Massachusetts. Boston, MA: Harvard School of Public Health; December 2014.

  9. Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003.

  10. Bunting RF Jr, Schukman J, Wong WB. A Comprehensive Guide to Managing Never Events and Hospital-Acquired Conditions. Washington, DC: Atlantic Information Services Inc.; 2009.

  11. Casey SM. Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error. 2nd ed. Santa Barbara, CA: Aegean Publishing Company; 1998.

  12. Columbia Accident Investigation Board. Report of the Columbia Accident Investigation Board; August 2003.

  13. Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. Cambridge, MA: Institute for Healthcare Improvement; 2010.

  14. Cook RI, Woods DD, Miller C. A Tale of Two Stories: Contrasting Views of Patient Safety. National Patient Safety Foundation at the AMA: Annenberg Center for Health Sciences; 1998.

  15. Dekker S. The Field Guide to Human Error Investigations. 3rd ed. Aldershot, UK: Ashgate Publishing; 2014.

  16. Dekker S. Just Culture: Balancing Safety and Accountability. 3rd ed. Boca Raton, FL: CRC Press; 2016.

  17. Donaldson L. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. London: The Stationery Office; 2000.

  18. Farley DO, Ridgely MS, Mendel P, et al. Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System. Santa Monica, CA: RAND Corporation; 2009.

  19. Gawande A. Complications: A Surgeon's Notes on an Imperfect Science. New York, NY: Metropolitan Books; 2002.

  20. Gawande A. Better: A Surgeon's Notes ...

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