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Cognition

Asimakopoulou K, Hampson SE.Cognitive Functioning and self-management in older people with diabetes. Diabetes Spectrum. 2002;15:116-121.

Booth GL, et al. Diabetes care in the U.S. and Canada. Diabetes Care. 2002;25:1149–1153.

Brands A, Biessels GJ, Dehann EHF, Kappelle LJ, Kessels. RPC: The effects of type 1 diabetes on cognitive performance. Diabetes Care. 2005;28:726-735.

Cooper JB, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiol 1978;49(6):399-406.

Cope JU, Morrison AE, Samuels-Reid J. Adolescent use of insulin and patient-controlled analgesia pump technology: a 10-year food and drug administration eetrospective study of adverse events. Pediatrics. 2008;121: e1133-e1138.

Communication

Andrus M, Roth M. Health literacy: a review. Pharmacother 2002;22(3):282-302.

Cook RI, Render M, Woods, DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320(7237):791-794.

Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and call for structure. Joint Commission Journal on Quality Improvement. 2007;33(1):34-47.

Dent S. Illiteracy: "Hidden disability" Creates Healthcare Confusion. FP Report 2000;6(1).

Department of Defense Patient Safety Program. Healthcare communications toolkit to improve transitions in care. Strategies and tools to improve healthcare handoffs and transitions. 2005. http://dodpatientsafety.usuhs.mil/files/Handoff_Toolkit.pdf

Gausman Benson J, Forman L. Comprehension of written healthcare information in an affluent geriatric retirement community: use of the Test of Functional Health Literacy. Gerontol. 2002;48(2):93-97.

Hellman (2006) Patient Safety and Inpatient Glycemic Control; Translating Concepts into Action

Kripalani S, et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007;297(8): 831-841.

Rudd R, Kirsch I, Yamamoto K. Literacy and Health in America. Policy Information Report. Princeton, NJ: Educational Testing Service; 2004.

Schwartzberg J. Health literacy: Can your patient read, understand, and act upon your instruction? J Med Pract Manage. 2003;18:281-283.

Smith PC. Missing clinical information during primary care visits. JAMA. 2005; 293(5):565-571.

Stein LI, Watts DT, Howell T. The doctor-nurse game revisited. N Engl J Med 1990;322(8):546-9.

Diabetes

Asimakopoulou K. Cognitive functioning and self-management in older people with diabetes. Diabetes Spectrum. 2002;15(2):116-121.

Brands A, et al. The Effects of Type 1 Diabetes on Cognitive Performance. Diabetes Care. 2005;28:726–735.

Clark Jr. CM, et al. Incorporating the Results of Diabetes Research Into Clinical Practice. Diabetes Care. 2001;24(12):2134-2142.

Cope JU, et al. Adolescent use of insulin and patient-controlled analgesia pump technology: A 10-year food and drug administration retrospective study of adverse events. Pediatrics. 2008;121(5):e1133-e1138.

Cox DJ, et al. Blood glucose awareness training (BGAT-2). Diabetes Care. 2001;24:637–642.

Cox DJ, et al. Diabetes and driving mishaps. Diabetes Care. 2003;26:2329–2334.

Cox DJ, et al. Relationships between hyperglycemia and cognitive performance among adults with type 1 and type 2 diabetes. Diabetes Care. 2005;28:71–77.

Egede L. Diabetes, Major Depression, and Functional Disability Among U.S. Adults. Diabetes Care. 2004;27:421–428.

Hellman (2004) A Systems Approach to Reducing Errors in Insulin Therapy in the Patient Setting

Hellman (2006) Patient Safety and Inpatient Glycemic Control; Translating Concepts into Action

Hellman (2007) The Perfect Storm - Drug Safety and Rosiglitazone

Hofer TP, et al. Profiling quality of care: Is there a role for peer review? BMC Health Services Research. 2004;4:9.

Jack Jr. L, et al. Understanding the environmental issues in diabetes self-management education research: a reexamination of 8 studies in community-based settings. Annals of Internal Medicine. 2004;140(11)964-972.

Mensing C, et al. National standards for diabetes self-management education. Diabetes Care. 2004;27(Sup1):S143-S150.

Norris S, et al. Effectiveness of self-management training in type 2 diabetes. A systematic review of randomized controlled trials. Diabetes Care. 2001;24:561–587.

Smith WD, et al. Causes of hyperglycemia and hypoglycemia in adult inpatients. Am J Health-Syst Pharm. 2005;62:714-719.

Thomas J, et al. A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care. 2003;26:2311–2317.

Trento MB, et al. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care. 2004;27:670–675.

Vallis M, et al. Stages of change for healthy eating in diabetes. Diabetes Care. 2003;26:1468–1474. Wing R. Behavioral interventions for obesity: Recognizing our progress and future challenges. Obesity Research. 2003;11(Sup):3S-6S.

Wysocki T, et al. Behavior therapy for families of adolescents with diabetes. Diabetes Care. 2001;24:441–446.

Drug Safety-Medical Erros

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA.1995;274(1):29-34.

Bates DW, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(25):1311-6.

Classen DC, et al. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA.1997;277:301-306.

Darves B. Seven simple steps to prevent outpatient drug errors. ACP Observer. June 2003.

Fast forward rounds: an effective method for teaching medical students to transition patients safely across care settings. Ouchida K, Lofaso VM, Capello CF, Ramsaroop S, Reid MC. J Am Geriatr Soc. 2009;57:910-917.

Gandhi TK, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Int Med. 2005;20:837-841.

Hurwitz B, Sheikh A, eds. Hoboken, NJ: Wiley-Blackwell; 2009. ISBN: 9781405146432.

Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007.

Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120.

Koppel R, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-203.

Lee JS. Computerized Physician Order Entry (CPOE) Systems. Research Synthesis, AcademyHealth, October 2002, http://www.academyhealth.org/syntheses/cpoe.htm. Accessed on August 9, 2006.

Medication errors in critical care: risk factors, prevention and disclosure. Camiré E, Moyen E, Stelfox HT. CMAJ. 2009;180:936-943.

Nadzam DM. Development of medication-use indicators by the Joint Commission on Accreditation of Healthcare Organizations. Am J Hosp Pharm. 1991;48(9):1925-30.

Philip Aspden, Julie A. Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Ed. Preventing Medication Errors. Institute of Medicine of the National Academies. The National Academies Press, 2007.

U.S. Pharmacopeia. No. 57: National council focuses on coordinating error reduction efforts. USP Quality Review. http://www.usp.org/hqi/practitionerPrograms/newsletters/qualityReview/qr571997-01-01.html. Accessed May 14, 2008.

U.S. Pharmacopeia. No. 76: Updated resource look-alike/sound-alike drugs. http://www.usp.org/hqi/practitionerPrograms/newsletters/qualityReview/qr762001-03-01.html. Accessed May 14, 2008.

Volpp KG, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med.2003;348(9)851-5.

Zhan C. Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am J Health-Sys Pharm. 2006;63(4):353-8.

Education

Clark Jr. CM, et al. Incorporating the results of diabetes research into clinical practice. Diabetes Care. 2001;24(12):2134-2142.

Holm, E., Patient education and morbidity in atopic eczema. Dermatology Nursing. 2005; 17(1): p. 35-45.

Jack Jr. L, et al. Understanding the environmental issues in diabetes self-management education research: a reexamination of 8 studies in community-based settings. Annals of Internal Medicine. 2004;140(11)964-972.

Leino-Kilpi H, et al. Patient education and health-related quality of life: surgical hospital patients as a case in point. J Nurs Care Qual. 2005;20(4):307-316.

Mensing C, et al. National standards for diabetes self-management education. Diabetes Care. 2004;27(Sup1):S143-S150.

Norris S, et al. Effectiveness of self-management training in type 2 diabetes. A systematic review of randomized controlled trials. Diabetes Care. 2001;24:561–587.

Rickheim PL, et al. Assessment of group versus individual diabetes education. A randomized study. Diabetes Care. 2002;25:269–274.

Washburn P. How to improve patient education. Hosp Topics. 2000;78(4).

Wysocki T, et al. Behavior therapy for families of adolescents with diabetes. Diabetes Care. 2001; 24:441–446.

Information Tech

AHRQ. Patient Safety Initiative: Building Foundations, Reducing Risk. Interim Report to the Senate Committee on Appropriations. Agency for Healthcare Research and Quality: Rockville, MD; 2003.

Aspden P, et al, eds. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academy Press; 2004.

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA.1995;274(1):29-34.

Bates DW, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280(25):1311-6.

Berwick D. A user's manual for the IOM's Quality Chasm report. Health Affairs 2002;21(3):80-90.

Darves B. Seven simple steps to prevent outpatient drug errors. ACP Observer. June 2003.

Gandhi TK, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Int Med. 2005;20:837-841.

Hellman (2006) Patient Safety and Inpatient Glycemic Control; Translating Concepts into Action

Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Washington, DC: National Academies Press; 2007.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academy Press; 1999.

Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120.

Koppel R, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005;293(10):1197-203.

Lee JS. Computerized Physician Order Entry (CPOE) Systems. Research Synthesis, AcademyHealth, October 2002, http://www.academyhealth.org/syntheses/cpoe.htm. Accessed on August 9, 2006.

Maguire P. Strategies to tackle outpatient errors. ACP-ASIM Observer. 2002.

Wald H, Shojania KG. Root cause analysis, in Making Healthcare Safer: A Critical Analysis of Patient Safety Practices., Shojania KG, et al., eds. Agency for Healthcare Research And Quality: Rockville, MD;2001:51-56.

Zhan C. Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am J Health-Sys Pharm. 2006;63(4):353-8.

Patient Factors

Andrus M, Roth M. Health literacy: a review. Pharmacother 2002;22(3):282-302.

Arora V, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Healthcare. 2005;14(6):401-7.

Cooper-Patrick L, et. al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999(282):583-589.

Dent S. Illiteracy: "Hidden disability" Creates Healthcare Confusion. FP Report 2000;6(1).

Fowles J, et al. Patients’ interest in reading their medical record. Arch Intern Med. 2004;164:793-800.

Gallagher TH, Waterman A, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001-1007.

Gausman Benson J, Forman L. Comprehension of written healthcare information in an affluent geriatric retirement community: use of the Test of Functional Health Literacy. Gerontol. 2002;48(2):93-97.

Kachalia A, et al. Does full disclosure of medical errors affect malpractice liability? Jt Comm J Qual Patient Saf. 2003;29:503-511.

Leino-Kilpi H, et al. Patient education and health-related quality of life: surgical hospital patients as a case in point. J Nurs Care Qual. 2005;20(4):307-316.

Massachusetts Coalition for the Prevention of Medical Errors. When things go wrong: responding to adverse events. A consensus statement of the Harvard hospitals. Boston; 2006.

Mazor KM, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med. 2004;140:409-418.

Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med 2004;140:409-418.

Norris S, et al. Effectiveness of self-management training in type 2 diabetes. A systematic review of randomized controlled trials. Diabetes Care. 2001;24:561–587.

Philibert I, Leach DC. Re-framing continuity of care for this century. Qual Saf Healthcare. 2005;14(6):394-6.

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: Professional boundaries, competency, and ethics. Annals of Internal Medicine. 2000;132(7):578-583.

Rudd R, Kirsch I, Yamamoto K. Literacy and Health in America. Policy Information Report. Princeton, NJ: Educational Testing Service; 2004.

Schwappach DL, Koeck CM. What makes an error unacceptable? A factorial survey on the disclosure of medical errors. Int J Qual Healthcare. 2004;16:317-326.

Schwartzberg J. Health literacy: Can your patient read, understand, and act upon your instruction? J Med Pract Manage. 2003;18:281-283.

Skinner TC, Hampson SE. Personal models of diabetes in relation to self-care, well-being, and glycemic control. Diabetes Care. 2001;24:828–833.

Smith WD, et al. Causes of hyperglycemia and hypoglycemia in adult inpatients. Am J Health-Syst Pharm. 2005;62:714-719.

The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff and consortium Representatives. A Clinical Practice Guideline for Treating Tobacco Use and Dependence. A US public health service report. JAMA. 2000;283:3244-3254.

National Patient Safety Foundation. Talking to patients about healthcare injury. Focus Patient Saf. 2001;4(1):3.

Thomas J, et al. A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care. 2003;26:2311–2317.

Trento MB, et al. A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care. 2004;27:670–675.

Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Arch Intern Med 1996;156:2565-2569.

Quality

Agency for Healthcare Research and Quality. Improving HealthCare Quality. September 2002;AHRQ Pub. No. 02-P032.

Clark Jr. CM, et al. Incorporating the Results of Diabetes Research Into Clinical Practice. Diabetes Care. 2001;24(12):2134-2142.

Eddy DM, Billings J. The quality of medical evidence: Implications for quality of care. Health Affairs. Spring 1988:19-32.

Eddy DM, Schlessinger L. Archimedes. Diabetes Care. 2003;26:3093–3101.

Eddy DM, Schlessinger L. Validation of the archimedes diabetes model. Diabetes Care. 2003;26:3102–3110.

Eddy DM. Balancing Cost and quality in fee-for-service versus managed care. Health Affairs. 1997;16(3):162-173.

Eddy DM. Performance measurement: Problems and solutions. Health Affairs. 1998;17(4):7-25.

Eddy DM. Successes and challenges of medical decision making. Health Affairs. Summer 1986:108-115.

Eddy DM. Variations in physician practice: The role of uncertainty. Health Affairs. 1984; 3 (2):74-89.

Elise C. Becher EC, Chassin MR. Improving Quality,Minimizing Error: Making It Happen. Health Affairs. 2001;20(3):68-81.

Hofer TP, et al. Profiling quality of care: Is there a role for peer review? BMC Health Services Research. 2004;4:9.

Mensing C, et al. National standards for diabetes self-management education. Diabetes Care. 2004;27(Sup1):S143-S150.

Norris S, et al. Effectiveness of self-management training in type 2 diabetes. A systematic review of randomized controlled trials. Diabetes Care. 2001;24:561–587.

Rickheim PL, et al. Assessment of group versus individual diabetes education. A randomized study. Diabetes Care. 2002;25:269–274.

Woolf SH. Patient Safety Is Not Enough: Targeting Quality Improvements To Optimize the Health of the Population. Annals of Internal Medicine. 2004;140(1):33-36.

Safety Culture

Adverse Events in Hospitals: Methods for Identifying Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.

Arora V, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Healthcare. 2005;14(6):401-7.

Aspden P, et al, eds. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academy Press; 2004.

Baker DP, et al. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Patient Saf. 2005;31(4):185-202.

Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320(7237):759-763.

Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med. 2001;345:663-8.

Berwick D. A user's manual for the IOM's Quality Chasm report. Health Affairs 2002;21(3):80-90.

Brennan T, et al. Incidence of adverse events and negligence in hospitalized patients of the Harvard Medical Practice Study I. N Engl J Med.1991;324:370-376.

California Academy of Family Physicians. Diagnosing and treating medical errors in family practice [Monograph]. 2002.

Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320:791-794.

Cope JU, Morrison AE, Samuels-Reid J. Adolescent Use of Insulin and Patient-Controlled Analgesia Pump Technology: A 10-Year Food and Drug Administration Retrospective Study of Adverse Events. Pediatrics 2008;121:e1133-e1138.

Darves B. Seven simple steps to prevent outpatient drug errors. ACP Observer. June 2003.

Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and call for structure. Joint Commission Journal on Quality Improvement. 2007;33(1):34-47.

DeBakey M. Bridging the communication gap in the operating room with medical team training. Am J Surg, 2005;190(5):770-4.

Department of Defense Patient Safety Program. Healthcare communications toolkit to improve transitions in care. Strategies and tools to improve healthcare handoffs and transitions. 2005. http://dodpatientsafety.usuhs.mil/files/Handoff_Toolkit.pdf

Hellman (2006) Patient Safety and Inpatient Glycemic Control; Translating Concepts into Action

Hickner JM, et al. Issues and initiatives in the testing process in primary care physician offices. Jt Comm J Qual Patient Saf. 2005;31(2):81-9.

Huber GA. Creating a safe environment. Health Affairs. 2003;22(4):41-43.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academy Press; 1999.

JCAHO Joint Commission announces 2006 national patient safety goals for ambulatory care and office-based surgery organizations. Viewpoint, the official newsletter of the American Academy of Ambulatory Care Nursing (AAACN). Jul/Aug 2005.

Landrigan, CP, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351(18):1838-1848.

Leape L, et al. The nature of adverse events in hospitalized patients. Results from the Harvard Medical School Study II. N Engl J Med.1991;324(6):377-84.

Lockley SW, et al. Effect of Reducing Interns’ Weekly Work Hours on Sleep and Attentional Failures. N Engl J Med.2004;351(18):1829-1837.

Maguire P. Strategies to tackle outpatient errors. ACP-ASIM Observer. 2002.

Mohr J, Arora V. Break the cycle: rooting out the workaround. ACGME Bull. 2004; Nov. 6-7.

Morey JC, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. HSR: Health Services Research. 2002;37(6):1553-1581.

Patient Safety Culture Surveys. March 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hospculture/.

Patterson ES, et al. Handoff strategies in settings with high consequences for failure: lessons for healthcare operations. Int J Qual Healthcare. 2004;16(2):125-32.

Pronovost PJ, et al. Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Qual Saf Healthcare. 2003;12(6):405-10.

Reason J, Carthey J, de Leval MR. Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management. Qual Healthcare. 2001;10 (supp 2):ii21-5.

Reason J. Human Error. New York, NY: Cambridge University Press; 1990.

Reason J. Safety in the operating theatre – part 2: human error and organisational failure. Current Anaesthesia and Critical Care. 1995;6:121-126.

Rogers AE, et al. The working hours of hospital staff nurses and patient safety. Health Affairs. 2004;23(4):202-212.

Roy CL, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121-8.

Sage WM. Medical Liability And Patient Safety. Health Affairs. 2003;22(4):26-36.

Schein E. Organizational culture. Am Psychol 1990;45;109-19.

Singer S, et al. The culture of safety: results of an organization-wide Survey in 15 California hospitals. Qual Saf Healthcare. 2003;12:112-8.

Solet DJ, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-9.

Traynor K. Adverse events occur after hospital discharge. Am J Health-System Pharm. 2003;60(6):534.

Vazirani S, et al. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14(1):71-7.

Volpp KG, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348(9)851-5.

Systems

AHRQ, Patient Safety Initiative: Building Foundations, Reducing Risk. Interim Report to the Senate Committee on Appropriations. 2003, Agency for Healthcare Research and Quality: Rockville, MD.

Altman DE, et al. Improving patient safety - five years after the IOM report. N Engl J Med. 2004;351:2041-2043.

Amalberti R, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142:756-764.

Aspden P, et al, eds. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academy Press; 2004.

Associates in Process Improvement. The Improvement Guide. 1996.

Astion ML, et al. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol. 2003;120(1):18-26.

Ayanian JZ. Rising rates of cardiac procedures in the United States and Canada. Circulation. 2006;113:333-335.

Baker GR, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. JAMC. 2004;170(11):1678-1686.

Baker GR. Harvard Medical Practice Study. Qual Saf Healthcare. 2004;13:151-152.

Baruch P. Patient safety and the reliability of health care systems. Ann Intern Med. 2003;138:997-998.

Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320(7237):759-763.

Becher EC, Chassin MR. Improving quality, minimizing error; making it happen. Health Affairs. 2001;20(3):68-81.

Bertalanffy LV. General System Theory: Foundations, Development, Applications. New York: George Braziller, Inc; 1968.

Berwick D. A user's manual for the IOM's Quality Chasm report. Health Affairs 2002;21(3):80-90.

Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969-1975.

Berwick DM. Errors today and errors tomorrow. N Engl J Med.2004;348:25.

Berwick DM. Lessons from developing nations on improving health care. BMJ. 2004;328:1124-1129.

Bismark M, Paterson R. Update; international report. Health Affairs. 2006;25:278—283.

Brennan T, et al. Incidence of adverse events and negligence in hospitalized patients of the Harvard Medical Practice Study I. N Engl J Med.1991;324:370-376.

Budetti PP. Tort reform and the patient safety movement. JAMA. 2005;293(21):2661-2662.

Clinton HR, Obama B. Making patient safety centerpeice of medical liability reform. N Engl J Med. 2006;354(21):2205-2208.

Cook RI, Render M, Woods, DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320(7237):791-794.

Davis P, et al. Adverse events regional feasibility study: indicative findings. NZ Med J 2001;114:203-5.

Davis P, et al. Adverse events regional feasibility study: methodological results. NZ Med J 2001;114:200-2.

Department of Veterans Affairs. VA/QUIC patient safety summit gives attendees plenty to take home. VA Quality Tips 2001.

Devers KJ, et al. What is driving hospitals' patient-safety efforts. Health Affairs. 2003;23(2):103-115.

DiNardo CRNP Donihi Pharm BCPS Bigi DeVita (2006) Evolution of a Diabetes Inpatient Safety Committee.

Dovey S, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Healthcare. 2002;11:233-238.

Feachen RGA, et al. Getting more for their dollar; a comparison of the NHS with California. BMJ 2002;324:135—143.

Fernald DH, et al. Event reporting to a primary care patient safety reporting system: a report from the ASIPS collaborative. Ann Fam Med. 2004;2(4):327-332.

Field RI, et al. Toward a policy agenda on medical research funding; results of a symposium. Health Affairs. 2003;22(3):224-230.

Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med. 2003;138:161-167.

Hatlie MJ, Sheridan SE. The medical liability crisis of 2003. Health Affairs. 2003;23(4):37-40.

Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;286(4):415-20.

Health and Safety Commission. Organizing for Safety: Third Report of the Human Factors Study Group of ACSNI. Sudbury: HSE Books; 1993.

Hellman (2006) Patient Safety and Inpatient Glycemic Control; Translating Concepts into Action

Hellman (2007) Effect of Intensive Treatment of Diabetes on the Risk of Death or Renal Failure

Hellman (2007) The Perfect Storm - Drug Safety and Rosiglitazone

Helmreich R, Merrit A. Culture at Work in Aviation and Medicine: National, Organizational, and Professional Influences. No. 176. Ashgate: Aldershot, UKM; 1998.

Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;137:327-333.

Hurwitz B. How does evidence based guidance influence determinations of medical negligence. BMJ 2004;329;1024-1028.

Implementing the SBAR technique. Jt Comm Perspect Patient Safety. 2006;6:8-12.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington: National Academy Press; 1999.

Jack L Jr., et al. Understanding the environmental issue in diabetes self-management education research. Ann Intern Med. 2004;140:964-971.

JCAHO Joint Commission announces 2006 national patient safety goals for ambulatory care and office-based surgery organizations. Viewpoint, the official newsletter of the American Academy of Ambulatory Care Nursing (AAACN). Jul/Aug 2005.

JCAHO. Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission Resources; 2006.

JCAHO. Sample Failure Mode, Effect, and Criticality Analysis. Available at: http://www.jointcommission.org/NR/rdonlyres

/8FFD02C0-D59C-4B0A-8899-088A5C86BE16/0/FMECA_Chart.PDF. Accessed 31 August 2006.

Lapetina EM, Armstrong EM. Preventing errors in the outpatient setting; A tale of three states. Health Affairs. 2004;21(4):26-39.

Layde P, et al. Patient safety efforts should focus on medical injuries. JAMA. 2002;287(15):1993-1997.

Leape L, Berwick D. Five years after To Err is Human: what have we learned? JAMA. 2005;293(19):2384-2390.

Leape LL, Berwick DM, Bates DW. What practices will most improve safety. JAMA. 2002;288(4):502-507.

Leape LL, et al. Pharmacist participation on physician rounds and adverse drug events in the ICU. JAMA. 1999;282:267-270.

Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA 2000;284(1):95-97.

Leape LL, et al. Promoting patient safety by preventing medical error. JAMA. 1998;280(16):1444-1447.

Leape LL. Reporting of adverse events. N Engl J Med. 2004;347(20):1633-1638.

Liang BA. Risks of reporting sentinel events. Health Affairs. 2000;19(5):112-120.

Longo DR, et al. The long road to patient safety. JAMA. 2005;294(22):2858-2865.

Makeham MA, et al. An international taxonomy for errors in general practice: a pilot study. Med J Aust. 2002;177(2):68-72.

McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284(1):93-5.

McGlynn EA, et al. Establishing national goals for quality improvement. Med Care. 2003;41(1 Suppl):16-29.

McNutt RA, et al. Patient safety efforts should focus on medical errors. JAMA 2002;287(15):1997-2001.

Michel P, et al. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. BMJ. 2004;328:199-200.

Millenson ML. The silence. Health Affairs. 2003;103-112.

Mohr J, Arora V. Break the cycle: rooting out the workaround. ACGME Bull. 2004; Nov. 6-7.

National Center for Healthcare Statistics. Hospital Utilization. Available at: http://www.cdc.gov/nchs/fastats/hospital.htm. Accessed August 16, 2006.

Pietro DA, et al. Detecting and reporting medical errors: why the dilemma? BMJ 2000;320(7237):794-796.

Poon EG, et al. I wish I had seen the results earlier. Arch Intern Med. 2004;164:2223-2228.

Reason J, Carthey J, de Leval MR. Diagnosing "vulnerable system syndrome": an essential prerequisite to effective risk management. Qual Healthcare. 2001;10 (supp 2):ii21-5.

Reason J. Human error: models and management. BMJ. 2000;320:768-770.

Reason J. Human Error. New York, NY: Cambridge University Press; 1990.

Runciman WB, et al. A comparison of iatrogenic injury studies in Australia and the USA. II: Reviewer behaviour and quality of care. Int J Qual Healthcare. 2000;12:379-388.

Schioler T, et al. Danish Adverse Event Study. [Incidence of adverse events in hospitals. A retrospective study of medical records]. Ugeskr Laeger. 2001;163(39):5370-5378.

Schoenbaum SC, Bovbjerg, RR. Malpractice reform must include steps to prevent medical injury. Ann Intern Med. 2004;140:51-53.

Schneider B, Goldstein H, Smith D. The ASA framework: an update. Pers Psychol 1995;40:747-773.

Senge P. The Fifth Discipline. New York: Doubleday; 1990.

Shojania KG, et al, eds. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Agency for Healthcare Research and Quality: Rockville, MD; 2001.

Shojania KG, et al. Safe but sound. Patient safety meets evidence-based medicine. JAMA. 2002;289(4):508-513.

Smith WD, et al. Causes of hyperglycemia and hypoglycemia in adult inpatients. Am J Health-Syst Pharm. 2005;62:714-719.

Thomas E, Peterson L. Measuring errors and adverse events in Healthcare. J Gen Intern Med. 2003;18:61-67.

Thomas EJ, et al. A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics. Int J Qual Healthcare. 2000;12:371-378.

Thomas EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261-71.

Van Cott H. Human errors: their causes and reduction, in Human Error in Medicine, Bogner MS, ed. Lawrence Erlbaum Associates: Hillsdale, NJ; 1994.

Vastag B. Donald M. Berwick, MD, MPP. Advocate for evidence-based health system reform. JAMA. 2004;291(16):1945-1947.

Vincent C, et al. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001;322:517-519.

Wachter RM, et al. Learning from our mistakes. Ann Intern Med. 2002;136:850-852.

Wachter RM. The end of the beginning: patient safety five years after 'to err is human.' Health Affairs. 2004;W4534-W4545.

Wald H, Shojania KG. Root cause analysis, in Making Healthcare Safer: A Critical Analysis of Patient Safety Practices., Shojania KG, et al., eds. Agency for Healthcare Research And Quality: Rockville, MD;2001:51-56.

Weissman JS, et al. Error reporting and disclosure systems. JAMA. 2005;293:1359-1366.

Wilson RM, et al. The Quality in Australia Healthcare Study. Med J Aust. 1995;163:458-76.

Zinn C. 14000 preventable deaths in Australian hospitals. BMJ. 1995;310:1487.