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ENGINEERING A CULTURE OF SAFETY
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Resources to Engineer a Culture of Safety

American Hospital Association. (2006). AHA hospital statistics. Chicago: Health Forum, LLC.
 

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Casey MM, Moscovice IS, Davidson G. (2006). Pharmacist staffing, technology use and implementation of medication safety practice in rural hospitals. Journal of Rural Health;22(4):321-329.
 

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Cohen MR. Medication errors: Causes, prevention, and risk management. Sudbury, MA: Jones and Bartlett Publishers; 2000.
 

Colla JB, Bracken AC, Kinney LM. (2005). Measuring patient safety climate: a review of surveys. Quality and Safety in Health Care,14:364-366.
 

Dillman DA. Mail and internet surveys: The tailored design method. New York: John Wiley & Sons; 2000.
 

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Edmonson AC. (2004). Learning from failure in health care: frequent opportunities, pervasive barriers. Quality and Safety in Health Care,13(Suppl II):ii3-ii9.
 

Flex Monitoring Team Site. August 2007. A complete list of Critical Access Hospitals. http://www.flexmonitoring.org/documents/CAH_LIST_08_06_07.xls.
 

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Forrey RA, Pedersen CA, Schneider PJ. (2007) Interrater agreement with a standard scheme for classifying medication errors. AJHP;64(2):175-181.
 

Gaba DM, Singer SJ, Rosen AK. (2007). Safety culture: is the “unit” the right “unit of analysis”? Critical Care Medicine, 35(1):314-316.
 

Greenwood DJ, Levin M. (2003). Reconstructing the relationship between universities and society through action research. In N. K. Denzin & Y.S. Lincoln (eds.), The Landscape of qualitative research: Theories and issues (pp. 131-166).Thousand Oaks: Sage Publications.
 

Health and Safety Commission (HSC). (1993). Organizing for safety: Third report of the human factors study group of ACSNI. Sudbury: HSE Books.
 

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Hicks RW, Becker SC, Cousins DD. (2006). MEMDARX data report: A chartbook of medication error findings from the perioperative settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety.
 

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Hospital Survey on Patient Safety Culture. Sorra J. and Nieva V. September 2004 Westat, AHRQ contract no. 290-96-0004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hospculture/  
 

Huang DT, Clermont G, Sexton JB. (2007). Perceptions of safety culture vary across the intensive care units of a single institution. Critical Care Medicine,35(1):165-176.
 

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Institute of Medicine. (2007). Preventing medication errors. Washington, DC: The National Academies Press.
 

Jones et al. (2006). http://www.unmc.edu/rural/documents/pr06-08.pdf
 

Jones KJ, Cochran G, Hicks RW, et al.(2004). Translating research into practice: voluntary reporting of medication errors in Critical Access Hospitals. Journal of Rural Health;20(4):335-343.
 

Jones KJ, Cochran G, Mueller K. (May 18, 2006). Prevalence of safe medication practices in small rural hospitals. Presented at the National Rural Health Association Meeting, Reno, NV. Manuscript in progress. Copy available from the authors.
 

Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000.
 

Leape LL. (2002). Reporting adverse events. New England Journal of Medicine, 347, 1633-1638.
 

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Marx D. (David Marx Consulting). Patient safety and the “Just Culture”: A primer for health care executives: In support of Columbia University. NIH R01 Hl53772. http://www.psnet.ahrq.gov/resource.aspx?resourceID=1582 
 

MEDMARX® National Medication Error Database [database online]. United States Pharmacopeia. Copyright 2007. https://www.medmarx.com/
 

Moscovice I, Rosenblatt R. (2000). Quality-of-care challenges for rural health. J Rural Health; 16:168-176.
 

Mueller KJ. (2004). The Medicare prescription drug, improvement, and modernization act of 2003 (P.L. 108-173): A summary of provisions important to rural health care delivery: RUPRI Center for Rural Health Policy Analysis. Policy Paper P2004-1.
 

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National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (1998). Taxonomy of medication errors. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf
 

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (2003). Council states comparing medication error rates is of no value. Retrieved February 20, 2004, from http://www.nccmerp.org/press/press2002-07-10a.html 
 

Neily J, Ogrinc G, Mills P et al. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Safe 2003;29(8):434-439.
 

Nieva VF, Sorra J. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Quality and Safety in Health Care,12(Suppl II):ii17-ii23.
 

Premier customized Excel™ data tool. Premier. http://www.premierinc.com/quality-safety/tools-services/safety/store/#custom-tool
 

Pronovost PJ, Berenholtz SM, Goeschel CA et al. (2006) Creating high reliability in health care organizations. HSR;41(4, Part II):1599-1617.
 

Reason, J. (1997) Managing the Risks of Organizational Accidents.Hampshire, England: Ashgate Publishing Limited.
 

Shojania KG, Duncan BW, McDonald KM, et al. (2001) Making health care safer. A critical analysis of patient safety practices. Evidence report/technology assessment number 43. Rockville, MD: Agency for Healthcare Research and Quality; July.
 

Singer SJ, Gaba DM,Geppert JJ et al. (2003) The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care;12:112-118.
 

Sorra J, Nieva VF, Famolaro T, Dyer N. (March 2007).Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. (Prepared by Westat, Rockville, MD, under contract No. 233-02-0087, Task Order No. 18). AHRQ Publication No. 07-0025. Rockville, MD: Agency for Healthcare Research and Quality.
 

Sorra J. and Nieva V. (September 2004). Hospital Survey on Patient Safety Culture. Westat, AHRQ contract no. 290-96-0004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hospculture/  
 

Stevenson JG. (2005). Medication errors: Experience of the United States Pharmacopeia. Joint Commission Journal on Quality and Safety;31(2):106-111.
 

TeamSTEPPS™: Strategies and Tools to Enhance Performance and Patient Safety. July 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/teamstepps/
 

The Patient Safety and Quality Improvement act of 2005. Agency for Healthcare Research and Quality, 2005. http://www.ahrq.gov/qual.psoact.htm.)
 

U.S. Census Bureau Site. August 2007. American Fact Finder. http://factfinder.census.gov
 

USP. (2002). Summary of information submitted to MEDMARXSM in the year 2000: Charting a course for change. Rockville, MD: USP Center for the Advancement of Patient Safety.
 

Van Leeuwen D. (1994). Are medication error rates useful as comparative measures of organization performance? Joint Commission Journal on Quality Improvement, 20, 192-199.
 

Wachter RM. (2004). The end of the beginning: Patient safety five years after ‘to err is human’ Health Affairs Web Exclusive, W4, 534-545.
 

Wald H, Shojania KG. (2001). Incident reporting. In: Making health care safer a critical analysis of patient safety practices. Evidence Report/Technology Assessment Number 43.  AHRQ Publication 01-E058 (pp. 41-50). http://www.ahcpr.gov/clinic/ptsafety/.
 

Weick KE, Sutcliffe KM. (2001). Managing the unexpected: Assuring high performance in an age of complexity. San Francisco: Josey-Bass;.
 

Westrum R. (2004). A typology of organizational cultures. Quality and Safety in Health Care,13:22-27.
 

Wiegmann DA, Zhang H, von Thaden T et al. (University of Illinois at Urbana-Champaign). (2002). A synthesis of safety culture and safety climate research. Prepared for Federal Aviation Administration;. Technical Report No.: ARL-02-3/FAA-02-2. Contract NO.: DTFA 01-G-015. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf
 

 

 
 

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