Preface xv

Acknowledgments xxiii

The Authors xxvii

Introduction 1

1 Declare Patient Safety Urgent and a Priority 12

2 Error and Harm in Health Care 23

3 Understanding the Basics of Patient Safety 44

4 Assume Executive Responsibility 71

5 Import New Knowledge and Skills 96

6 Install a Blameless Reporting System 120

7 Assign Accountability 148

8 Align External Controls and Reform Education 181

9 Accelerate Change For Improvement 204

10 The End of the Beginning 234

References 245

Glossary 255

Appendixes

1 Checklist for Assessing Institutional Resilience 279

2 Creating De-Identified Case Studies for Dissemination 283

3 Medical Accidents Policy: Reporting and Disclosure,

Including Sentinel Events 285

4 Medication Safety Team Feedback Form 295

5 Patient Safety Workplan 297

6 Safety Learning Report 300

7 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 303

8 Complexity Lens Reflection 308

9 A Brief Look at Gaps in the Continuity of Care 311

10 A Brief Look at the New Look in Complex System Failure, Error, and Safety 313

11 A Reminder on Every Chart 315

12 List of Serious Reportable Events in Health Care 316

13 Statement of Principle: Talking to Patients About Health Care Injury 321

14 VHA Patient Safety Organizational Assessment 322

Additional Readings 331

Resources 335

Index 345