References

¹Agency for Healthcare Research and Quality (AHRQ) website. (n.d.). https://www.ahrq.gov

²Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41. doi: 10.1046/j.1365-2648.2001.01820.x

³Bagian JP, Gosbee JW. 2000. Developing a culture of patient safety at the VA. Ambulatory Outreach Spring:25–29.

⁴Bagian JP, Lee C, Gosbee J, Derosier J, Stalhandske E, Eldridge N, Williams R, Burkhardt M. 2001. Developing and deploying a patient safety program in a large health care delivery systems: You can’t fix what you don’t know about. The Joint Commission Journal on Quality Improvement 27(10):522–532.

⁵Aenean lacinia bibendum nulla sed consectetur. Maecenas faucibus mollis interdum. Nulla vitae elit libero, a pharetra augue. Vivamus sagittis lacus vel augue laoreet rutrum faucibu.

⁶Barach P, Small S. 2000. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal 320:759–763.

⁷C M. The problem with incident reporting. – NCBI. 2016.

⁸Cooper M. 2000. Towards a model of safety culture. Safety Science 36:111–136.

⁹DuPree, E. (2016). High reliability: The path to zero harm. Healthcare Executive, 31(1), 66-69.

¹⁰Evidence Scan: Measuring Safety Culture. London, UK: The Health Foundation, 2011.

¹¹Famolaro, T., Yount, N., Burns, W. et al. (2016, March). Hospital survey on patient safety culture 2016 user comparative database report. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved May 23, 2018, from www.ahrq.gov: http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patientsafety/patientsafetyculture/hospital/2016/2016_hospitalsops_report_pt1.pdf

¹²Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, 2015.

¹³Gorini, A., Miglioretti, M., & Pravettoni, G. (2012). A new perspective on blame culture: An experimental study. Journal of Evaluation in Clinical Practice, 18(3), 671-675. doi:10.1111/j.1365-2753.2012.01831.x

¹⁴Grant S. 1999. Who’s to blame for tragic error? American Journal of Nursing 99(9):9.

¹⁵Griffith, K., & Marx, D. (2012). Just culture a shared committment. Quality and Safety in Radiology, 52-58.

¹⁶Henneman, P. L., Marquard, J. L., & Fisher, D. L. (2012). Bar-code verification: Reducing but not eliminating medication errors. Journal of Nursing Administration, 42, 562-566. doi:10.1097/nna.0b013e318274b545

¹⁷Hines S, Luna K, Lofthus J. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. In: Prepared by the Lewin Group under Contract N, ed. Rockville, MD: Agency for Healthcare Research and Quality, 2008.

¹⁸Illingworth J. Continuous improvement of patient safety | The Health Foundation, 2015.

¹⁹Institute of Medicine (IOM). 2000. To Err Is Human: Building a Safer Health System . Washington, DC: National Academy Press.

²⁰Institute of Medicine (US) Committee on the Work Environment for Nurses and Patient Safety; Page A, editor. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington (DC): National Academies Press (US); 2004. 7, Creating and Sustaining a Culture of Safety. Available from: https://www.ncbi.nlm.nih.gov/books/NBK216181

²¹Joint Commission. (2017). The essential role of leadership in developing a safety culture. Sentinel Event Alert Issue 57. Retrieved May 23, 2018 from https://www.jointcommission.org/assets/1/18/SEA_57_Safety_Culture_Leadership_0317.pdf

²²Jones B. 2002. Nurses and the Code of Silence. Medical Error . San Francisco, CA: Jossey-Bass.

²³Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture inhealth care. Health Care Manager Review, 34(4), 312-322. doi:10.1097/hmr.0b013e3181a3b709

²⁴King, C. (2010). To err is human, to drift is normalization of deviance. AORN Journal, 91(2), 284-286.

²⁵Kohn LTC, J.M.; Donaldson M.S. To Err Is Human: Building a Safer Health System. In: America CoQHCi, ed. Institute of Medicine. Washington, DC: National Academy of Sciences, 2000.

²⁶Kohn, K. T., Corrigan, J. M. & Donaldson, M. S. (2000). To err is human: Building a safer health system, Washington, DC: National Academy Press.

²⁷Leape L. 1994. Error in medicine. Journal of the American Medical Association 272:1851–1857.

²⁸Makary MA, Daniel M. Medical error—the third leading cause of death in the US. 2016 doi: 10.1136/bmj.i2139

²⁹Manasse H, Turnbull J, Diamond L. 2002. Patient safety: A review of the contemporary American experience. Singapore Medical Journal 43(5):254–262.

³⁰Marx, D. (2001). Patient safety and the “just culture”. A primer for health care executives. Retrieved from: http://www.safer.healthcare.ucla.edu/safer/archive/ahrq/FinalPrimerDoc.pdf

³¹Marx, D. (2017). The just culture certification course. Retrieved from https://www.outcomeeng.com/getting-to-know-just-culture/

³²Medicare Payment Advisory Commission. 1999. Report to the Congress: Selected Medicare Issues. Washington, DC: Medicare Payment Advisory Commission.

³³Osborne J, Blais K, Hayes J. 1999. Nurses’ perceptions: When is it a medication error? Journal of Nursing Administration 29(4):33–38.

³⁴Outcome Engenuity LLC (2012). Just culture: Training for managers.

³⁵Patient Safety Network website. (n.d.). https://psnet.ahrq.gov

³⁶Pizzi L, Goldfarb N, Nash D. 2001. Promoting a culture of safety. In: Shojania K, editor; , Duncan B, editor; , McDonald K, editor; , Wachter R, editor. , eds. Making HealthCare Safer: A Critical Analysis of Patient Safety Practices . Rockville, MD: AHRQ.

³⁷Reason, J. (1990). Human Error. Cambridge: Cambridge University Press.

³⁸Aenean lacinia bibendum nulla sed consectetur. Maecenas faucibus mollis interdum. Nulla vitae elit libero, a pharetra augue. Vivamus sagittis lacus vel augue laoreet rutrum faucibu.

³⁹Sari AB ea. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. – NCBI. 2016.

⁴⁰Aenean lacinia bibendum nulla sed consectetur. Maecenas faucibus mollis interdum. Nulla vitae elit libero, a pharetra augue. Vivamus sagittis lacus vel augue laoreet rutrum faucibu.

⁴¹Sirota, R. L. (2005). Error and error reduction in pathology. Archives of Pathology & Laboratory Medicine, 129(10), 1228-1233.

⁴²Sirriyeh, R., Lawton, R., Armitage, G., Gardner, P., & Ferguson, S. (2012). Safety subcultures in health-care organizations and managing medical error. Health Services Management Research, 25(1), 16-23. doi:10.1258/hsmr.2011.011018.

⁴³Spath P. 2000. Does your facility have a “patient-safe” climate? Hospital Peer Review 25:80–82.

⁴⁴Aenean lacinia bibendum nulla sed consectetur. Maecenas faucibus mollis interdum. Nulla vitae elit libero, a pharetra augue. Vivamus sagittis lacus vel augue laoreet rutrum faucibu.

⁴⁵Tracy E. 1999. Evolving practice and a culture of safety. QRC Advisor 15(10):10–12.

⁴⁶Vincent C. Patient Safety. UK: BMJ Books 2010.

⁴⁷Vogus TJ, Sutcliffe KM, Weick KE. Doing no harm: Enabling, enacting, and elaborating a culture of safety in health care. Academy of Management Perspectives 2010;24(4):60-77.

⁴⁸Aenean lacinia bibendum nulla sed consectetur. Maecenas faucibus mollis interdum. Nulla vitae elit libero, a pharetra augue. Vivamus sagittis lacus vel augue laoreet rutrum faucibu.

⁴⁹Weick KE, Sutcliffe KM. Managing The Unexpected: Resilent Performance in an Age of Uncertainty. San Francisco, CA: John Wiley and Sons, Inc 2007.

⁵⁰Weiner, B., Hobgood, C., & Lewis, M. (2008). The meaning of justice in safety incident reporting. Social Science & Medicine, 66, 403-413. doi:10.1016/j.socscimed.2007.08.013.

⁵¹Wolf, Z. & Hughes, R. (2011). Chapter 35. Error reporting and disclosure. Retrieved May 23, 2018 from https://archive.ahrq.gov/professionals/cliniciansproviders/resources/nursing/resources/nurseshdbk/WolfZ_ERED.pdf