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| Foreword | |
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| Preface | |
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| Contributors | |
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| Understanding the First Institute of Medicine Report and Its Impact on Patient Safety | |
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| Summary of Crossing the Quality Chasm: A New System for the 21st Century | |
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| Interpersonal Relationships: The "Soft Stuff" of Patient Safety | |
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| An Organization Development Framework for Transformational Change in Patient Safety: A Guide for Hospital Senior Leaders | |
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| Toward a Philosophy of Patient Safety: Expanding the Systems Approach to Medical Error | |
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| The Fallacy of the Body Count: Why the Interest in Patient Safety and Why Now? | |
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| Mistaking Error | |
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| The Investigation and Analysis of Clinical Incidents | |
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| Patient Safety and Error Reduction Standards: The JCAHO Response to the IOM Report | |
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| Applying Epidemiology to Patient Safety | |
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| Patient Safety Is an Organizational Systems Issue: Lessons from a Variety of Industries | |
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| Admitting Imperfection: Revelations from the Cockpit for the World of Medicine | |
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| Reporting and Preventing Medical Mishaps: Safety Lessons Learned from Nuclear Power | |
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| Trial and Error in My Quest to Be a Partner in My Health Care: A Patient's Story | |
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| Health Care Literacy and Patient Safety: The New Paradox | |
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| Using a Root Cause Analysis Process to Analyze Issues of Safety | |
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| The Leadership Role of the Chief Operating Officer in Aligning Strategy and Operations to Create Patient Safety | |
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| The Successful Quality Professional: Framework, Attributes, and Roles | |
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| The Role of the Risk Manager in Creating Patient Safety | |
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| Reducing Medical Errors: The Role of the Physician | |
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| Engaging General Counsel in the Pursuit of Safety | |
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| Growing Nursing Leadership in the Field of Patient Safety | |
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| Engaging the Board of Directors and Creating a Governance Structure | |
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| Teamwork Communications and Training | |
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| Teamwork: The Fundamental Building Block of High-Reliability Organizations and Patient Safety | |
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| Moving Beyond Blame to Create an Environment that Rewards Reporting | |
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| Addressing Clinician Performance Problems as a Systems Issue | |
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| Advancing Patient and Health Care Worker Safety by Preventing Infections | |
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| The Baldridge Approach to Patient Safety | |
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| Outlining the Business Case for Patient Safety | |
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| The Economics of Patient Safety | |
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| The Role of Ethics and Ethics Services in Patient Safety | |
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| How We Started Patient Safety in Israel: Without a Budget but with Enthusiasm | |
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| Public Legislation and Professional Self-Regulation: Quality and Safety Efforts in Norwegian Health Care | |
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| The Handling of a Catastrophic Medical Error Event: A Case Study in the Use of a Systemic Mindful Approach to Error Reduction | |
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| Why, What, and How Ought Harmed Parties Be Told? The Art, Mechanics, and Ambiguities of Error Disclosure | |
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| Disclosure of Medical Error: Liability, Insurance, and Risk Management Implications | |
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| Medical Error and Patient Safety: Communicating with the Media | |
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| Using Best Practices to Improve Medication Safety | |
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| Improving the Safety of the Medication Use Process | |
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| Designing a Safer System for Medications: A Case Study | |
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| One Organization's Advocacy Effort for Error Prevention: The Institute for Safe Medication Practices | |
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| The Role of the Laboratory in Patient Safety | |
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| Partnership and Collaboration on Patient Safety with Health Care Suppliers | |
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| Patient Safety Training and New Technology | |
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| No-Fault Compensation for Medical Injuries: The Prospect for Error Prevention | |
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| The Criminalization of Health Care: When Is Medical Malpractice a Crime? | |
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| What Does the Leapfrog Group Portend for Hospitals and Physicians? | |
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| The Future of Patient Safety: Reflections on History, the Data, and What It Will Take to Succeed | |
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| Index | |