Preface.

Acknowledgments.

The Authors.

Introduction.

1. Declare Patient Safety Urgent and a Priority.

2. Error and Harm in Health Care.

3. Understanding the Basics of Patient Safety.

4. Assume Executive Responsibility.

5. Import New Knowledge and Skills.

6. Install a Blameless Reporting System.

7. Assign Accountability.

8. Align External Controls and Reform Education.

9. Accelerate Change For Improvement.

10. The End of the Beginning.

References.

Glossary.

Appendixes.

1. Checklist for Assessing Institutional Resilience.

2. Creating De-Identified Case Studies for Dissemination.

3. Medical Accidents Policy: Reporting and Disclosure, Including Sentinel Events.

4. Medication Safety Team Feedback Form.

5. Patient Safety Workplan.

6. Safety Learning Report.

7. Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety.

8. Complexity Lens Reflection.

9. A Brief Look at Gaps in the Continuity of Care.

10. A Brief Look at the New Look in Complex System Failure, Error, and Safety.

11. A Reminder on Every Chart.

12. List of Serious Reportable Events in Health Care.

13. Statement of Principle: Talking to Patients About Health Care Injury.

14. VHA Patient Safety Organizational Assessment.

Additional Readings.

Resources.

Index.