APPENDIX I: Key Books, Reports, Series, and Websites on Patient Safety

Key Books and Reports on Medical Errors and Errors More Generally

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 ...