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

Apkon, M, et al. ‘Design of a Safer Approach to Intravenous Drug Infusions: Failure Mode Effects Analysis’. Quality and Safety in Health Care, vol. 13, no. 4, 2004, pp. 265–71, https://doi.org/10.1136/qshc.2003.007443.

Apkon, M., et al. ‘Design of a Safer Approach to Intravenous Drug Infusions: Failure Mode Effects Analysis’. Quality & Safety in Health Care, vol. 13, no. 4, 2004, pp. 265–71, https://doi.org/10.1136/qshc.2003.007443.

Armitage, 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, vol. 36, no. 8, 2010, pp. 358–351, https://doi.org/10.1016/S1553-7250(10)36053-3.

Barach, Paul, and Stephen D. Small. ‘Reporting and Preventing Medical Mishaps: Lessons from Non-Medical near Miss Reporting Systems’. BMJ, vol. 320, no. 7237, 2000, pp. 759–63, https://doi.org/10.1136/bmj.320.7237.759.

---. ‘Reporting and Preventing Medical Mishaps: Lessons from Non-Medical near Miss Reporting Systems’. BMJ: British Medical Journal, vol. 320, no. 7237, 2000, pp. 759–63, https://doi.org/10.1136/bmj.320.7237.759.

Barber, N., et al. ‘Failure Mode and Effects Analysis: Views of Hospital Staff in the UK’. Journal of Health Services Research and Policy, vol. 17, no. 1, 2012, pp. 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.

Benn, J., et al. ‘Feedback from Incident Reporting: Information and Action to Improve Patient Safety’. Quality and Safety in Health Care, vol. 18, no. 1, 2009, pp. 11–21, https://doi.org/10.1136/qshc.2007.024166.

---. ‘Feedback from Incident Reporting: Information and Action to Improve Patient Safety’. Quality & Safety in Health Care, vol. 18, no. 1, 2009, pp. 11–21, https://doi.org/10.1136/qshc.2007.024166.

Berwick, Donald M., et al. Curing Health Care: New Strategies for Quality Improvement : A Report on the National Demonstration Project on Quality Improvement in Health Care. Jossey-Bass, 2002.

Bicheno, John, et al. Six Sigma: And the Quality Toolbox for Service and Manufacturing. Rev. ed, Picsie Books, 2005.

---. The New Lean Toolbox: Towards Fast, Flexible Flow. 3rd ed, PICSIE Books, 2004.

---. The Service Systems Toolbox: Integrating Lean Thinking, Systems Thinking, and Design Thinking. PICSIE Books, 2012.

Burke, John P. ‘Infection Control — A Problem for Patient Safety’. New England Journal of Medicine, vol. 348, no. 7, 2003, pp. 651–56, https://doi.org/10.1056/NEJMhpr020557.

Burke, John P. ‘Infection Control--a Problem for Patient Safety’. The New England Journal of Medicine, vol. 348, no. 7, 2003, pp. 651–56, http://0-search.proquest.com.pugwash.lib.warwick.ac.uk/docview/223934778?accountid=14888.

Chassin, Mark R. ‘The Wrong Patient’. Annals of Internal Medicine, vol. 136, no. 11, 2002, pp. 826–33, https://doi.org/10.7326/0003-4819-136-11-200206040-00012.

Cohen, M. D., and P. B. Hilligoss. ‘The Published Literature on Handoffs in Hospitals: Deficiencies Identified in an Extensive Review’. BMJ Quality & Safety, vol. 19, no. 6, 2010, pp. 493–97, https://doi.org/10.1136/qshc.2009.033480.

Cohen, M.D., 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, 2010, pp. 493–97, https://doi.org/10.1136/qshc.2009.033480.

Cook, Richard I., et al. ‘Gaps in the Continuity of Care and Progress on Patient Safety’. BMJ, vol. 320, no. 7237, 2000, pp. 791–94, https://doi.org/10.1136/bmj.320.7237.791.

---. ‘Gaps in the Continuity of Care and Progress on Patient Safety’. BMJ: British Medical Journal, vol. 320, no. 7237, 2000, pp. 791–94, https://doi.org/10.1136/bmj.320.7237.791.

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

de Vries, E N, et al. ‘The Incidence and Nature of In-Hospital Adverse Events: A Systematic Review’. Quality and Safety in Health Care, vol. 17, no. 3, 2008, pp. 216–23, https://doi.org/10.1136/qshc.2007.023622.

de Vries, E.N., et al. ‘The Incidence and Nature of In-Hospital Adverse Events: A Systematic Review’. Quality & Safety in Health Care, vol. 17, 2008, pp. 216–23, https://doi.org/10.1136/qshc.2007.023622.

Dekker, Sidney. Patient Safety: A Human Factors Approach. electronic resource, CRC Press, Taylor & Francis Group, 2011, http://0-marc.crcnetbase.com.pugwash.lib.warwick.ac.uk/isbn/9781439852262.

Dekker, Sidney, and Sidney Dekker. The Field Guide to Understanding Human Error. 2nd ed, electronic resource, 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.

---. The Field Guide to Understanding Human Error. Ashgate, 2006.

Deming, W. Edwards. Out of the Crisis. 1st MIT Press ed, MIT Press, 2000.

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.

Donaldson, Liam J. and Great Britain. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS. Stationery Office, 2000.

Edvardsson, Bo, et al. Quality of Service: Making It Really Work. McGraw-Hill, 1994.

Flin, Rhona H., et al. Safety at the Sharp End: A Guide to Non-Technical Skills. 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.

---. Safety at the Sharp End: A Guide to Non-Technical Skills. Ashgate, 2008.

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.

Hollnagel, Erik, David D. Woods, et al. Resilience Engineering: Concepts and Precepts. Ashgate, 2006.

Hollnagel, Erik, Jeffrey Braithwaite, et al. Resilient Health Care. Ashgate, 2013.

Hollnagel, Erik. Resilient Health Care Volume 2,. The Resilience of Everyday Clinical Work. 2nd edition.

Kohn, Linda T., et al. To Err Is Human: Building a Safer Health System. National Academy Press, 2000.

Leonard, Michael Steven, et al. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Health Administration Press, 2004.

Liker, Jeffrey K., and David Meier. The Toyota Way Fieldbook: A Practical Guide for Implementing Toyota’s 4Ps. electronic resource, McGraw-Hill, 2006, http://lib.myilibrary.com/browse/open.asp?id=86287&entityid=https://idp.warwick.ac.uk/idp/shibboleth.

---. The Toyota Way Fieldbook: A Practical Guide for Implementing Toyota’s 4Ps. McGraw-Hill, 2006.

Managing Competing Organizational Priorities in Clinical Handover across Organizational Boundaries. http://hsr.sagepub.com/content/20/1_suppl/17.full.

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

McKee, Martin. ‘Improving the Safety of Patients in England’. BMJ: British Medical Journal, vol. 347, no. 7921, 2013, pp. f5038–f5038, https://doi.org/10.1136/bmj.f5038.

McNulty, Terry, and Ewan Ferlie. Reengineering Health Care: The Complexities of Organizational Transformation. Oxford University Press, 2004.

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.

Norman, Donald A. The Psychology of Everyday Things. Basic Books, 1988.

Patterson, E. S., 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, 2010, pp. 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.

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

---. Normal Accidents: Living with High-Risk Technologies. Princeton University Press, 1999.

Raduma-Tomas, M. A., et al. ‘Doctors’ Handovers in Hospitals: A Literature Review’. BMJ Quality & Safety, vol. 20, no. 2, 2011, pp. 128–33, https://doi.org/10.1136/bmjqs.2009.034389.

Reason, J. ‘Human Error: Models and Management’. BMJ, vol. 320, no. 7237, 2000, pp. 768–70, https://doi.org/10.1136/bmj.320.7237.768.

Reason, J. T. Human Error. Cambridge University Press, 1990.

---. Managing the Risks of Organizational Accidents. Ashgate, 1997.

---. Managing the Risks of Organizational Accidents. Ashgate, 1997.

Reason, James. ‘Human Error: Models and Management’. BMJ: British Medical Journal, vol. 320, 2000, pp. 768–70, https://doi.org/10.1136/bmj.320.7237.768.

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

Schonberger, Richard. Best Practices in Lean Six Sigma Process Improvement: A Deeper Look. electronic resource, John Wiley & Sons, 2008, http://lib.myilibrary.com/browse/open.asp?id=109440&entityid=https://idp.warwick.ac.uk/idp/shibboleth.

---. Best Practices in Lean Six Sigma Process Improvement: A Deeper Look. John Wiley & Sons, 2008.

Seddon, John. Freedom from Command & Control: Rethinking Management for Lean Service. Productivity Press, 2005.

Shojania, K. G. ‘The Frustrating Case of Incident-Reporting Systems’. Quality and Safety in Health Care, vol. 17, no. 6, 2008, pp. 400–02, https://doi.org/10.1136/qshc.2008.029496.

---. ‘The Frustrating Case of Incident-Reporting Systems’. Quality and Safety in Health Care, vol. 17, no. 6, 2008, pp. 400–02, https://doi.org/10.1136/qshc.2008.029496.

Slack, Nigel, et al. Operations Management. 7th edition, Pearson Education UK, 2013, http://lib.myilibrary.com/browse/open.asp?id=502442&entityid=https://idp.warwick.ac.uk/idp/shibboleth.

---. Operations Management. Seventh edition, Pearson, 2013.

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

Sujan, 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, vol. 30, no. 10, 2013, pp. 873–873, https://doi.org/10.1136/emermed-2013-203113.17.

Sujan, Mark A. ‘A Novel Tool for Organisational Learning and Its Impact on Safety Culture in a Hospital Dispensary’. Reliability Engineering & System Safety, vol. 101, 2012, pp. 21–34, https://doi.org/10.1016/j.ress.2011.12.021.

Taxis, K, and N. Barber. ‘Causes of Intravenous Medication Errors: An Ethnographic Study’. Quality and Safety in Health Care, vol. 12, no. 5, 2003, pp. 343–47, https://doi.org/10.1136/qhc.12.5.343.

Taxis, K., and N. Barber. ‘Causes of Intravenous Medication Errors: An Ethnographic Study’. Quality & Safety in Health Care, vol. 12, no. 5, 2003, pp. 343–47, https://doi.org/10.1136/qhc.12.5.343.

The Importance of Human Resources Management in Health Care: A Global Context. http://www.human-resources-health.com/content/4/1/20.

Vincent, Charles, et al. ‘Adverse Events in British Hospitals: Preliminary Retrospective Record Review’. BMJ, vol. 322, no. 7285, 2001, pp. 517–19, https://doi.org/10.1136/bmj.322.7285.517.

---. ‘Adverse Events in British Hospitals: Preliminary Retrospective Record Review’. BMJ: British Medical Journal, vol. 322, 2001, pp. 517–19, https://doi.org/10.1136/bmj.322.7285.517.

---. Patient Safety. Wiley-Blackwell, 2010.

Walshe, K, 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, 2001, pp. 250–56, https://doi.org/10.1136/qhc.0100250.

Walshe, K., 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, 2001, pp. 250–56, https://doi.org/10.1136/qhc.0100250.

Weick, Karl E., and Kathleen M. Sutcliffe. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed, electronic resource, 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.

---. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. 2nd ed, Jossey-Bass, 2007.

Womack, James P., et al. The Machine That Changed the World. New ed, Simon & Schuster, 2007.

Womack, James P., and Daniel T. Jones. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. Rev. and Updated, Simon & Schuster, 2003.