1. Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 1999. Available at: http://books.nap.edu/books/0309068371/html/index.html. Accessed July 23, 2003.
2. Senate Appropriations Labor, Health and Human Services, Education, and Related Agencies Committee Appropriation Bill, 2001. Report 106-293 (May 12, 2000), p. 195-198. Available at: http://frwebgate.access.gpo.gov/cgi-bin/useftp.cgi?IPaddress=162.140.64.21&filename=sr293.106&directory=/disk2/wais/data/106_cong_reports. Accessed July 7, 2003.
3. Harkin T. Committee on Appropriations, Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Bill, 2002. Report 107-84 (Oct 11, 2001). Available at: http://frwebgate.access.gpo.gov/cgi-bin/useftp.cgi?IPaddress=162.140.64.21&filename=sr084.107&directory=/diskb/wais/data/107_cong_reports. Accessed July 7, 2003.
4. Reason, J. Managing the Risk of the Organizational Accident. Aldershot, England; Ashgate: 1997.
5. Kraman S, Hamm G. Risk management: extreme honesty may be the best policy. Ann Int Med 1999;131:963-7.
6. Lamb RM, Studdert DM, Bohmer RM, Berwick DM, Brennan TA. Hospital disclosure practices: results of a national survey. Health Aff (Millwood) 2003 Mar-Apr;22(2):73-83.
7. Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289(8):1001-7.
8. Battles JB, van der Schaaf TW, Shea CE, Mercer SQ. Identification and classification of the causes of transfusion medicine. Transfusion 1998;38;1071-81.
9. Battles J, Keyes M. Technology and patient safety: a two-edged sword. Management & Technology 2002 March/April; 84-8.
10. Blazy ME. We All Know About ASRS, But What's An ASRP? FAAviation News Magazine 1999 October.
11. Overhage, M. Presentation to the IOM. Winter, 2003. Available at: http://www.iom.edu/file.asp?id=10972. Accessed July 30, 2003.
12. Riley T, Rosenthal, J. Patient Safety and Medical Errors: A Road Map for State Action. Portland, ME; National Academy for State Health Policy (NASHP): 2001.
13. Flowers L, Riley T. State-based Mandatory Reporting of Medical Errors. Portland, ME; National Academy for State Health Policy (NASHP): 2001.
14. Rosenthal J, Booth M, Flowers L, Riley T. Current State Programs Addressing Medical Errors: An analysis of Mandatory Reporting and Other Initiatives. Portland, ME; National Academy for State Health Policy (NASHP): 2001.
15. Riley, T. Improving Patient Safety: What States Can Do about Medical Errors. Portland, ME: National Academy for State Health Policy (NASHP): 2000.
16. The Healthcare Research and Quality Act of 1999, Pub. L. No. 106-129, (Dec. 6, 1999).
17. National Advisory Council for Healthcare Research and Quality. April 2003. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/about/council.htm. Accessed June 17, 2003.
18. The Quality Interagency Coordination Task Force (QuIC). Doing what counts for patient safety: Federal actions to reduce medical errors and their impact. 2000 Feb.
19. Wachter RM, McDonald KM. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment Number 43 (Prepared by UCSF-Stanford Evidence-Based Practice Center.) AHRQ Publication No. 01-E058. Rockville, MD; Agency for Healthcare Research and Quality: July 2001. Available at: http://www.ahrq.gov/clinic/ptsafety/. Accessed December 15, 2003.
20. Kovner, C. The impact of staffing and the organization of work on patient outcomes and health care workers in health care organizations. Journal on Quality Improvement 2001;27(9):458-68.
21. The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment Number 74. (Prepared by Oregon Health and Science University Evidence-based Practice Center.) Rockville, MD: Agency for Healthcare Research and Quality: 2003.
22. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 2002;288(4):501-7.
23. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Safe but sound: patient safety meets evidence-based medicine. JAMA 2002;288(4):508-13.
24. Safe Practices for Better Health Care. Washington, DC; National Quality Forum: 2003.
| Acronym | Agency Name |
|---|---|
| AHRQ | Agency for Healthcare Research and Quality |
| CBER | Center for Biologics Evaluation and Research, FDA |
| CDRH | Center for Devices and Radiological Health, FDA |
| CDC | Centers for Disease Control and Prevention |
| CERTs | Centers for Education and Research on Therapeutics |
| CMS | Centers for Medicare & Medicaid Services |
| CQuIPS | Center for Quality Improvement and Patient Safety |
| DCERPS | Developing Centers of Excellence in Patient Safety Research |
| DHHS | Department of Health and Human Services |
| DoD | Department of Defense |
| FDA | Food and Drug Administration |
| HIV | Human Immunodeficiency Virus |
| HMO | Health Maintenance Organization |
| IDSRN | Integrated Delivery System Research Network |
| IOM | Institute of Medicine |
| IT | Information Technology |
| JAMA | Journal of the American Medical Association |
| JCAHO | Joint Commission on the Accreditation of Healthcare Organizations |
| M&M | Morbidity and Mortality |
| NASHP | National Academy for State Health Policy |
| NQF | National Quality Forum |
| PSIC | Patient Safety Improvement Corps |
| PSRCC | Patient Safety Research Coordinating Center |
| PSTF | Patient Safety Task Force |
| QuIC | Quality Interagency Coordination Task Force |
| RFA | Request for Applications |
| ULP | User Liaison Program |
| VA | Department of Veterans Affairs |