Bibliography for MH940: Improving Safety & Quality in Health Care BETA

1

The importance of human resources management in health care: a global context. http://www.human-resources-health.com/content/4/1/20

2

Berwick DM, Godfrey AB, Roessner J. Curing health care: new strategies for quality improvement : a report on the National Demonstration Project on Quality Improvement in Health Care. San Francisco, Calif: : Jossey-Bass 2002.

3

Bicheno J. The service systems toolbox: integrating lean thinking, systems thinking, and design thinking. Buckingham: : PICSIE Books 2012.

4

Bicheno J. The new lean toolbox: towards fast, flexible flow. 3rd ed. Buckingham: : PICSIE Books 2004.

5

Bicheno J, Catherwood P, James R. Six sigma: and the quality toolbox for service and manufacturing. Rev. ed. Buckingham: : Picsie Books 2005.

6

Cusins P. Understanding Quality through Systems Thinking. TQM magazine 1994;6:19–27.http://0-www.emeraldinsight.com.pugwash.lib.warwick.ac.uk/doi/pdfplus/10.1108/09544789410067853

7

Deming WE. Out of the crisis. 1st MIT Press ed. Cambridge, Mass: : MIT Press 2000.

8

Edvardsson B, Øvretveit J, Thomasson B. Quality of service: making it really work. Maidenhead: : McGraw-Hill 1994.

9

Liker JK, Meier D. The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps. New York: : McGraw-Hill 2006. http://lib.myilibrary.com/browse/open.asp?id=86287&entityid=https://idp.warwick.ac.uk/idp/shibboleth

10

Liker JK, Meier D. The Toyota way fieldbook: a practical guide for implementing Toyota’s 4Ps. New York: : McGraw-Hill 2006.

11

McNulty T, Ferlie E. Reengineering health care: the complexities of organizational transformation. Oxford: : Oxford University Press 2004.

12

Schonberger R. Best practices in lean six sigma process improvement: a deeper look. Hoboken, N.J.: : John Wiley & Sons 2008. http://lib.myilibrary.com/browse/open.asp?id=109440&entityid=https://idp.warwick.ac.uk/idp/shibboleth

13

Schonberger R. Best practices in lean six sigma process improvement: a deeper look. Hoboken, N.J.: : John Wiley & Sons 2008.

14

Seddon J. Freedom from command & control: rethinking management for lean service. New York: : Productivity Press 2005.

15

Slack N, Brandon-Jones A, Johnston R. Operations management. 7th edition. Boston, Mass: : Pearson Education UK 2013. http://lib.myilibrary.com/browse/open.asp?id=502442&entityid=https://idp.warwick.ac.uk/idp/shibboleth

16

Slack N, Brandon-Jones A, Johnston R. Operations management. Seventh edition. Harlow, England: : Pearson 2013.

17

Spear S, Kent Bowen H. Decoding the DNA of the Toyota Production System. Harvard business review 1999;77:96–106.http://0-search.ebscohost.com.pugwash.lib.warwick.ac.uk/direct.asp?db=bth&jid=HBR&scope=site

18

Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation. Rev. and updated. London: : Simon & Schuster 2003.

19

Womack JP, Jones DT, Roos D. The machine that changed the world. New ed. London: : Simon & Schuster 2007.

20

Reason JT. Human error. Cambridge [England]: : Cambridge University Press 1990.

21

Dekker S, Dekker S. The field guide to understanding human error. 2nd ed. Farnham: : Ashgate Publishing Ltd 2006. https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9781472408402

22

Dekker S, Dekker S. The field guide to understanding human error. Aldershot, England: : Ashgate 2006.

23

Norman DA. The psychology of everyday things. New York: : Basic Books 1988.

24

Chassin MR. The Wrong Patient. Annals of Internal Medicine 2002;136:826–33. doi:10.7326/0003-4819-136-11-200206040-00012

25

Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Quality and Safety in Health Care 2001;10:250–6. doi:10.1136/qhc.0100250

26

Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Quality in Health Care 2001;10:250–6. doi:10.1136/qhc.0100250

27

Healthcare Commission. Investigation into outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust. 2007.http://webarchive.nationalarchives.gov.uk/20060502043818/http://healthcarecommission.org.uk/_db/_documents/Maidstone_and_Tunbridge_Wells_investigation_report_Oct_2007.pdf

28

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry - Executive summary. 2013.http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

29

National Advisory Group on the Safety of Patients in England. Berwick Report into Improving the Safety of Patient. 2013.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

30

McKee M. Improving the safety of patients in England. BMJ 2013;347:5038–5038. doi:10.1136/bmj.f5038

31

McKee M. Improving the safety of patients in England. BMJ: British medical journal 2013;347:f5038–f5038. doi:10.1136/bmj.f5038

32

Vincent C. Patient safety. Chichester, West Sussex, UK: : Wiley-Blackwell 2010.

33

Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, D.C.: : National Academy Press 2000.

34

Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517–9. doi:10.1136/bmj.322.7285.517

35

Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ: British medical journal 2001;322:517–9. doi:10.1136/bmj.322.7285.517

36

de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Quality and Safety in Health Care 2008;17:216–23. doi:10.1136/qshc.2007.023622

37

de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Quality & safety in health care 2008;17:216–23. doi:10.1136/qshc.2007.023622

38

Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Quality and Safety in Health Care 2003;12:343–7. doi:10.1136/qhc.12.5.343

39

Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Quality & safety in health care 2003;12:343–7. doi:10.1136/qhc.12.5.343

40

Burke JP. Infection Control — A Problem for Patient Safety. New England Journal of Medicine 2003;348:651–6. doi:10.1056/NEJMhpr020557

41

Burke JP. Infection control--a problem for patient safety. The New England Journal of Medicine 2003;348:651–6.http://0-search.proquest.com.pugwash.lib.warwick.ac.uk/docview/223934778?accountid=14888

42

Donaldson LJ, Great Britain. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: : Stationery Office 2000.

43

Department of Health. Safety First: a report for patients, clinicians and healthcare managers. 2006.http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_064159.pdf

44

Reason J. Human error: models and management. BMJ 2000;320:768–70. doi:10.1136/bmj.320.7237.768

45

Reason J. Human Error: Models and Management. BMJ: British medical journal 2000;320:768–70. doi:10.1136/bmj.320.7237.768

46

Reason JT. Managing the risks of organizational accidents. Aldershot, Hants, England: : Ashgate 1997.

47

Dekker S. Patient safety: a human factors approach. Boca Raton: : CRC Press, Taylor & Francis Group 2011. http://0-marc.crcnetbase.com.pugwash.lib.warwick.ac.uk/isbn/9781439852262

48

Perrow C. Normal Accidents: Living with High Risk Technologies. Princeton: : Princeton University Press 2011. http://WARW.eblib.com/patron/FullRecord.aspx?p=827819

49

Perrow C. Normal accidents: living with high-risk technologies. Princeton, NJ: : Princeton University Press 1999.

50

Leonard MS, Frankel A, Simmonds T, et al. Achieving safe and reliable healthcare: strategies and solutions. Chicago, IL: : Health Administration Press 2004.

51

Reason JT. Managing the risks of organizational accidents. Aldershot, Hants, England: : Ashgate 1997.

52

Apkon M, Leonard J, Vitale R, et al. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Quality and Safety in Health Care 2004;13:265–71. doi:10.1136/qshc.2003.007443

53

Apkon M, Leonard J, Probst L, et al. Design of a safer approach to intravenous drug infusions: failure mode effects analysis. Quality & safety in health care 2004;13:265–71. doi:10.1136/qshc.2003.007443

54

Armitage G, Neary M, Hollingsworth G, et al. A practical guide to Failure Mode and Effects Analysis in health care: Making the most of the team and its meetings. Joint Commission Journal on Quality and Patient Safety 2010;36:358–351. doi:10.1016/S1553-7250(10)36053-3

55

Barber N, Franklin B, Burnett S, et al. Failure mode and effects analysis: Views of hospital staff in the UK. Journal of Health Services Research and Policy 2012;17:37–43.https://arlir.iii.com/nonret~S0&atitle=Failure+mode+and+effects+analysis:+Views+of+hospital+staff+in+the+UK&title=Journal+of+Health+Services+Research+and+Policy&aufirst=N.&auinit=&aulast=Barber&issn=13558196&eissn=&coden=&volume=17&issue=1&spage=37&epage=43&quarter=&ssn=&date=2012&sid=&reqtype3

56

Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759–63. doi:10.1136/bmj.320.7237.759

57

Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ: British Medical Journal 2000;320:759–63. doi:10.1136/bmj.320.7237.759

58

Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care 2009;18:11–21. doi:10.1136/qshc.2007.024166

59

Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Quality & safety in health care 2009;18:11–21. doi:10.1136/qshc.2007.024166

60

Shojania KG. The frustrating case of incident-reporting systems. Quality and Safety in Health Care 2008;17:400–2. doi:10.1136/qshc.2008.029496

61

Shojania KG. The frustrating case of incident-reporting systems. Quality and Safety in Health Care 2008;17:400–2. doi:10.1136/qshc.2008.029496

62

Sujan MA. A novel tool for organisational learning and its impact on safety culture in a hospital dispensary. Reliability Engineering & System Safety 2012;101:21–34. doi:10.1016/j.ress.2011.12.021

63

Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Farnham: : Ashgate Publishing Ltd 2008. https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9781472424006

64

Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot, England: : Ashgate 2008.

65

Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. BMJ Quality & Safety 2010;19:493–7. doi:10.1136/qshc.2009.033480

66

Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Quality & safety in health care 2010;19:493–7. doi:10.1136/qshc.2009.033480

67

Raduma-Tomas MA, Flin R, Yule S, et al. Doctors’ handovers in hospitals: a literature review. BMJ Quality & Safety 2011;20:128–33. doi:10.1136/bmjqs.2009.034389

68

Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal On Quality And Patient Safety 2010;36:52–61.https://arlir.iii.com/nonret~S0&atitle=Patient+handoffs:+standardized+and+reliable+measurement+tools+remain+elusive.&title=Joint+Commission+Journal+On+Quality+And+Patient+Safety&aufirst=E.S.&auinit=&aulast=Patterson&issn=15537250&eissn=&coden=&volume=36&issue=2&spage=52&epage=61&quarter=&ssn=&date=2010&sid=&reqtype3

69

Sujan M, Chessum PT, Rudd M, et al. Emergency Care Handover (ECHO study) across care boundaries – the need for joint decision making and consideration of psychosocial history. Emergency Medicine Journal 2013;30:873–873. doi:10.1136/emermed-2013-203113.17

70

Managing competing organizational priorities in clinical handover across organizational boundaries. http://hsr.sagepub.com/content/20/1_suppl/17.full

71

Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: : Jossey-Bass 2007. https://www.dawsonera.com/guard/protected/dawson.jsp?name=https://idp.warwick.ac.uk/idp/shibboleth&dest=http://www.dawsonera.com/abstract/9780470178591

72

Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco: : Jossey-Bass 2007.

73

Hollnagel E, Woods DD, Leveson N. Resilience engineering: concepts and precepts. Aldershot, England: : Ashgate 2006.

74

Hollnagel E, Braithwaite J, Wears RL. Resilient health care. Farnham: : Ashgate 2013.

75

Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791–4. doi:10.1136/bmj.320.7237.791

76

Cook RI, Render M, Woods DD. Gaps in the Continuity of Care and Progress on Patient Safety. BMJ: British medical journal 2000;320:791–4. doi:10.1136/bmj.320.7237.791

77

Hollnagel E. Resilient health care Volume 2,. The resilience of everyday clinical work. 2nd edition. Ashgate, 2015: