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

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D. M. Berwick, A. B. Godfrey, and J. Roessner, 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.

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

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

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

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P. Cusins, ‘Understanding Quality through Systems Thinking’, TQM magazine, vol. 6, no. 5, pp. 19–27, 1994 [Online]. Available: http://0-www.emeraldinsight.com.pugwash.lib.warwick.ac.uk/doi/pdfplus/10.1108/09544789410067853

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

[8]

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

[9]

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

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

[11]

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

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

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

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

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

[16]

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

[17]

S. Spear and H. Kent Bowen, ‘Decoding the DNA of the Toyota Production System’, Harvard business review, vol. 77, no. 5, pp. 96–106, 1999 [Online]. Available: http://0-search.ebscohost.com.pugwash.lib.warwick.ac.uk/direct.asp?db=bth&jid=HBR&scope=site

[18]

J. P. Womack and D. T. Jones, Lean thinking: banish waste and create wealth in your corporation, Rev. and Updated. London: Simon & Schuster, 2003.

[19]

J. P. Womack, D. T. Jones, and D. Roos, The machine that changed the world, New ed. London: Simon & Schuster, 2007.

[20]

J. T. Reason, Human error. Cambridge [England]: Cambridge University Press, 1990.

[21]

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

[22]

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

[23]

D. A. Norman, The psychology of everyday things. New York: Basic Books, 1988.

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M. R. Chassin, ‘The Wrong Patient’, Annals of Internal Medicine, vol. 136, no. 11, pp. 826–833, 2002, doi: 10.7326/0003-4819-136-11-200206040-00012. [Online]. Available: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.7326/0003-4819-136-11-200206040-00012

[25]

K. Walshe and N. Offen, ‘A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary’, Quality and Safety in Health Care, vol. 10, no. 4, pp. 250–256, 2001, doi: 10.1136/qhc.0100250.

[26]

K. Walshe and N. Offen, ‘A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary’, Quality in Health Care, vol. 10, no. 4, pp. 250–256, 2001, doi: 10.1136/qhc.0100250. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/10/4/250

[27]

Healthcare Commission, ‘Investigation into outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust’. 2007 [Online]. Available: 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 [Online]. Available: 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 [Online]. Available: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf

[30]

M. McKee, ‘Improving the safety of patients in England’, BMJ, vol. 347, pp. 5038–5038, 2013, doi: 10.1136/bmj.f5038.

[31]

M. McKee, ‘Improving the safety of patients in England’, BMJ: British medical journal, vol. 347, no. 7921, pp. f5038–f5038, 2013, doi: 10.1136/bmj.f5038. [Online]. Available: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/347/bmj.f5038

[32]

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

[33]

L. T. Kohn, J. Corrigan, and M. S. Donaldson, To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000.

[34]

C. Vincent, G. Neale, and M. Woloshynowych, ‘Adverse events in British hospitals: preliminary retrospective record review’, BMJ, vol. 322, no. 7285, pp. 517–519, 2001, doi: 10.1136/bmj.322.7285.517.

[35]

C. Vincent, G. Neale, and M. Woloshynowych, ‘Adverse events in British hospitals: preliminary retrospective record review’, BMJ: British medical journal, vol. 322, pp. 517–519, 2001, doi: 10.1136/bmj.322.7285.517. [Online]. Available: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/322/7285/517

[36]

E. N. de Vries, M. A. Ramrattan, S. M. Smorenburg, D. J. Gouma, and M. A. Boermeester, ‘The incidence and nature of in-hospital adverse events: a systematic review’, Quality and Safety in Health Care, vol. 17, no. 3, pp. 216–223, 2008, doi: 10.1136/qshc.2007.023622.

[37]

E. N. de Vries, M. A. Ramrattan, S. M. Smorenburg, D. J. Gouma, and M. A. Boermeester, ‘The incidence and nature of in-hospital adverse events: a systematic review’, Quality & safety in health care, vol. 17, pp. 216–223, 2008, doi: 10.1136/qshc.2007.023622. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/17/3/216.full

[38]

K. Taxis and N. Barber, ‘Causes of intravenous medication errors: an ethnographic study’, Quality and Safety in Health Care, vol. 12, no. 5, pp. 343–347, 2003, doi: 10.1136/qhc.12.5.343.

[39]

K. Taxis and N. Barber, ‘Causes of intravenous medication errors: an ethnographic study’, Quality & safety in health care, vol. 12, no. 5, pp. 343–347, 2003, doi: 10.1136/qhc.12.5.343. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/12/5/343.full

[40]

J. P. Burke, ‘Infection Control — A Problem for Patient Safety’, New England Journal of Medicine, vol. 348, no. 7, pp. 651–656, 2003, doi: 10.1056/NEJMhpr020557.

[41]

J. P. Burke, ‘Infection control--a problem for patient safety’, The New England Journal of Medicine, vol. 348, no. 7, pp. 651–656, 2003 [Online]. Available: http://0-search.proquest.com.pugwash.lib.warwick.ac.uk/docview/223934778?accountid=14888

[42]

L. J. Donaldson and 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 [Online]. Available: 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]

J. Reason, ‘Human error: models and management’, BMJ, vol. 320, no. 7237, pp. 768–770, 2000, doi: 10.1136/bmj.320.7237.768.

[45]

J. Reason, ‘Human Error: Models and Management’, BMJ: British medical journal, vol. 320, pp. 768–770, 2000, doi: 10.1136/bmj.320.7237.768. [Online]. Available: http://0-www.jstor.org.pugwash.lib.warwick.ac.uk/stable/25187420

[46]

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

[47]

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

[48]

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

[49]

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

[50]

M. S. Leonard, A. Frankel, T. Simmonds, and K. B. Vega, Achieving safe and reliable healthcare: strategies and solutions, vol. ACHE management series. Chicago, IL: Health Administration Press, 2004.

[51]

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

[52]

M. Apkon, J. Leonard, R. Vitale, L. DeLizio, and L. Probst, ‘Design of a safer approach to intravenous drug infusions: failure mode effects analysis’, Quality and Safety in Health Care, vol. 13, no. 4, pp. 265–271, 2004, doi: 10.1136/qshc.2003.007443.

[53]

M. Apkon, J. Leonard, L. Probst, L. DeLizio, and R. Vitale, ‘Design of a safer approach to intravenous drug infusions: failure mode effects analysis’, Quality & safety in health care, vol. 13, no. 4, pp. 265–271, 2004, doi: 10.1136/qshc.2003.007443. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/13/4/265.full

[54]

G. Armitage, M. Neary, G. Hollingsworth, and L. Ashley, ‘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, vol. 36, no. 8, pp. 358–351, 2010, doi: 10.1016/S1553-7250(10)36053-3. [Online]. Available: http://www.jointcommissionjournal.com/article/S1553-7250(10)36053-3/pdf

[55]

N. Barber, B. Franklin, S. Burnett, A. Parand, and N. Shebl, ‘Failure mode and effects analysis: Views of hospital staff in the UK’, Journal of Health Services Research and Policy, vol. 17, no. 1, pp. 37–43, 2012 [Online]. Available: 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]

P. Barach and S. D. Small, ‘Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems’, BMJ, vol. 320, no. 7237, pp. 759–763, 2000, doi: 10.1136/bmj.320.7237.759.

[57]

P. Barach and S. D. Small, ‘Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems’, BMJ: British Medical Journal, vol. 320, no. 7237, pp. 759–763, 2000, doi: 10.1136/bmj.320.7237.759. [Online]. Available: http://0-www.jstor.org.pugwash.lib.warwick.ac.uk/stable/25187418

[58]

J. Benn et al., ‘Feedback from incident reporting: information and action to improve patient safety’, Quality and Safety in Health Care, vol. 18, no. 1, pp. 11–21, 2009, doi: 10.1136/qshc.2007.024166.

[59]

J. Benn et al., ‘Feedback from incident reporting: information and action to improve patient safety’, Quality & safety in health care, vol. 18, no. 1, pp. 11–21, 2009, doi: 10.1136/qshc.2007.024166. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/18/1/11.full

[60]

K. G. Shojania, ‘The frustrating case of incident-reporting systems’, Quality and Safety in Health Care, vol. 17, no. 6, pp. 400–402, 2008, doi: 10.1136/qshc.2008.029496.

[61]

K. G. Shojania, ‘The frustrating case of incident-reporting systems’, Quality and Safety in Health Care, vol. 17, no. 6, pp. 400–402, 2008, doi: 10.1136/qshc.2008.029496. [Online]. Available: http://0-dx.doi.org.pugwash.lib.warwick.ac.uk/10.1136/qshc.2008.029496

[62]

M. A. Sujan, ‘A novel tool for organisational learning and its impact on safety culture in a hospital dispensary’, Reliability Engineering & System Safety, vol. 101, pp. 21–34, 2012, doi: 10.1016/j.ress.2011.12.021. [Online]. Available: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1016/j.ress.2011.12.021

[63]

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

[64]

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

[65]

M. D. Cohen and P. B. Hilligoss, ‘The published literature on handoffs in hospitals: deficiencies identified in an extensive review’, BMJ Quality & Safety, vol. 19, no. 6, pp. 493–497, 2010, doi: 10.1136/qshc.2009.033480.

[66]

M. D. Cohen and P. B. Hilligoss, ‘The published literature on handoffs in hospitals: deficiencies identified in an extensive review’, Quality & safety in health care, vol. 19, no. 6, pp. 493–497, 2010, doi: 10.1136/qshc.2009.033480. [Online]. Available: http://0-qualitysafety.bmj.com.pugwash.lib.warwick.ac.uk/content/19/6/493.full

[67]

M. A. Raduma-Tomas, R. Flin, S. Yule, and D. Williams, ‘Doctors’ handovers in hospitals: a literature review’, BMJ Quality & Safety, vol. 20, no. 2, pp. 128–133, 2011, doi: 10.1136/bmjqs.2009.034389. [Online]. Available: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1136/bmjqs.2009.034389

[68]

E. S. Patterson and R. L. Wears, ‘Patient handoffs: standardized and reliable measurement tools remain elusive.’, Joint Commission Journal On Quality And Patient Safety, vol. 36, no. 2, pp. 52–61, 2010 [Online]. Available: 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]

M. Sujan et al., ‘Emergency Care Handover (ECHO study) across care boundaries – the need for joint decision making and consideration of psychosocial history’, Emergency Medicine Journal, vol. 30, no. 10, pp. 873–873, 2013, doi: 10.1136/emermed-2013-203113.17. [Online]. Available: http://0-doi.org.pugwash.lib.warwick.ac.uk/10.1136/emermed-2013-203113.17

[70]

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[71]

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

[72]

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

[73]

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

[74]

E. Hollnagel, J. Braithwaite, and R. L. Wears, Resilient health care, vol. Ashgate studies in resilience engineering. Farnham: Ashgate, 2013.

[75]

R. I. Cook, M. Render, and D. D. Woods, ‘Gaps in the continuity of care and progress on patient safety’, BMJ, vol. 320, no. 7237, pp. 791–794, 2000, doi: 10.1136/bmj.320.7237.791.

[76]

R. I. Cook, M. Render, and D. D. Woods, ‘Gaps in the Continuity of Care and Progress on Patient Safety’, BMJ: British medical journal, vol. 320, no. 7237, pp. 791–794, 2000, doi: 10.1136/bmj.320.7237.791. [Online]. Available: http://0-www.bmj.com.pugwash.lib.warwick.ac.uk/content/320/7237/791

[77]

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