Introduction by Mildred K. Lehman
Chapter 1: Understanding the First IOM Report and Its Impact on Patient Safety
Chapter 2: The Second Report on Safety from the IOM: Crossing the Quality Chasm
Chapter 3: Interpersonal Relationships: The "Soft Stuff" of Patient Safety
Chapter 4: An Organization Development Framework for Transformation to a Culture of Safety
Chapter 5: Toward a Philosophy of Patient Safety: Expanding the Systems Approach to Medical Error
Chapter 6: The Fallacy of the Body Count: Why the Interest in Patient Safety and Why Now?
Chapter 7: Fallacies on Counting Error
Chapter 8: The Investigation and Analysis on Clinical Incidents
Chapter 9: Patient Safety and Errors Reduction Standards
Chapter 10: Applying Epidemiology in Patient Safety
Chapter 11: Patient Safety Is an Organizational Systems Issue: Lessons from a Variety of Industries
Chapter 12: Admitting Imperfection: Revelations from the Cockpit for the World of Medicine
Chapter 13: Reporting and Preventing Medical Mishaps: Safety Lessons Learned from Nuclear Power
Chapter 14: Trial and Error in My Quest to be a Partner in My Healthcare
Chapter 15: Health Care Literacy and Patient Safety: The New Paradox
Chapter 16: Using Root Cause Analysis to Analyze Issues of Safety
Chapter 17: The Leadership Role of the Chief Operating Officer in Aligning Strategy and Operations
Chapter 18: The Successful Quality Professional: Framework, Attributes, and Roles
Chapter 19: The Role of the Risk Manager in Creating Patient Safety
Chapter 20: Reducing Medical Errors: The Role of the Physician
Chapter 21: Engaging General Counsel in the Pursuit of safety
Chapter 22: Growing Nursing Leadership in the Field of Patient Safety
Chapter 23: Engaging the Board of Directors and Creating a Governance Structure
chapter 24: Teamwork Communications and Training
Chapter 25: Teamwork: The Fundamental Building Block of High Reliability Organizations and Patient Safety
Chapter 26: Moving Beyond Blame to Create an Environment that Rewards Reporting
Chapter 27: Addressing Clinician Performance Problems as a Systems Issue
Chapter 28: Advancing Patient Complaint and Healthcare Worker Safety by Preventing Infections
Chapter 29: The Baldridge Approach to Patient Safety
Chapter 30: Outlining the Business Case for Patient Safety
Chapter 31: The Economics of Patient Safety
Chapter 32: The Role of Ethics and Ethics Services in Patient Safety
Chapter 33: What Can One Learn from the Canadian Approach to Patient Safety?
Chapter 34: How We Started Patient Safety in Israel
Chapter 35: Public Legislation and Professional Self-Regulation: Quality and Safety Efforts in Norwegian Health Care
Chapter 36: The Handling of a Catastrophic Medical Error Event: A Case Study
Chapter 37: Why, What, and How Ought Harmed Parties be Told? The Art, Mechanics, and Ambiguities
Chapter 38: Disclosure of Medical Error: Liability, Insurance, and Risk Management Implications
Chapter 39: Medical Error and Patient Safety: Communicating with the Media
Chapter 40: Using Best Practices to Improve Medication Safety
Chapter 41: Improving the Safety of the Medication Use Process
Chapter 42: Designing a Safer Systems for Medications: A Case Study
Chapter 43: One Organization's Advocacy Effort for Error Prevention: Institute For Safe Medical Practices
Chapter 44: The Role of the Laboratory in Patient Safety
Chapter 45: Partnership and Collaboration on Patient Safety with Health Care Suppliers
Chapter 46: Patient Safety Training and New Technology
Chapter 47: No-Fault Compensation for Medical Injuries: Prospect for Error Prevention
Chapter 48: The Criminalization of Health Care: When is Medical Malpractice a Crime?
Chapter 49: That Does the Leapfrog Group Portend for Health Care Providers?
Chapter 50: The Future of Patient Safety: Reflections on History, the Data, and What it Will take to Succeed