Bismark MM. The power of apology. New Zealand Medical Journal. 2009 Oct;122(1304):96-106.

An apology to the patient following an adverse event can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust in their relationship. Yet, for many practitioners saying "I'm sorry" remains a difficult thing to do. This article explores the key elements of a full apology and when they should be used, and how to support practitioners in making an apology to patients who have been harmed.

Peto RR, Tenerowicz LM, Benjamin EM, Morsi DS, Burger PK. One system's journey in creating a disclosure and apology program. Joint Commission Journal on Quality and Patient Safety. 2009 Oct;35(10):487-496.

In 2006 Baystate Health in Massachusetts began implementing a formal disclosure and apology program to support prompt and skillful disclosure of adverse events. The hospital trained coaches and established and expanded emotional support services for patients, families, and clinicians. This article describes their experience to date, including key challenges and lessons learned.

Adler L, Denham CR, McKeever M, Purunton R, Guilloteau F, Moorhead D, Resar R. Global Trigger Tool: Implementation basics. Journal of Patient Safety. 2008 Dec;4(4):245-249.

This article has been written to assist front-line community hospitals that are contemplating using the IHI Global Trigger Tool methodology to measure overall harm (adverse events). The experience of Florida Hospital is described, from initial leadership agreement, to team training, and finally to lessons learned in setting up an ongoing system of harm measurement using the IHI Global Trigger Tool.

Nance J
Bozeman, Montana: Second River Healthcare Press; 2008

An internationally recognized medical/patient safety and aviation safety expert, John Nance has been a leader in applying aviation safety concepts such as crew resource management in health care settings for numerous years. In this book, he describes the new and different (and sometimes radical) methods for supporting front-line hospital staff in providing safe, high-quality care for patients.

Conway JB, Weingart SN. Leadership: Assuring respect and compassion to clinicians involved in medical error. Swiss Medical Weekly. 2009;139(1-2):3.

An editorial about respect and compassion for the “second victims” of medical errors: clinicians.

Resar RK, Rozich JD, Simmonds T, Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Joint Commission Journal on Quality and Patient Safety. Oct 2006;32(10):585-590.

The Trigger Tool technique was used to identify the rate of occurrence of adverse events in the intensive care unit (ICU), and a subset of ICUs described those events in detail. Sixty-two ICUs in 54 hospitals (both academic and community) engaged in IHI critical care collaboratives between 2001 and late 2004. Charts were selected using a random sampling technique and reviewed using a two-stage process.

Boothman RC, Blackwell AC, Campbell DA Jr, Commiskey E, Anderson S. A better approach to medical malpractice claims? The University of Michigan experience. Journal of Health and Life Sciences Law. 2009 Jan;2(2):125-159.

This case example of the University of Michigan Health System’s experience suggests that a response by the medical community more directly aimed at what drives patients to call lawyers would more effectively reduce malpractice claims. More importantly, honest assessments of medical care give rise to clinical improvements that reduce patient injuries. [This article is made available with the permission of the American Health Lawyers Association. No additional distribution is permitted without the express permission of the Association. The Journal of Health and Life Sciences Law is available for purchase here.]

Frankel A, Leonard M, Simmonds T, Haraden C (editors)
Chicago: Joint Commission Resources with the Institute for Healthcare Improvement; 2008

This book is geared to help patient safety leaders create a culture of safety; plan, oversee, and implement new safety practices and improve safety-related management and operations. The material is applicable to community hospitals, teaching hospitals, health care systems, rural/critical access hospitals, and ambulatory care settings. Best practices, strategies, and tips are provided, including chapter-length case studies from nationally recognized health care organizations.

Schwappach D, Boluarte T. The emotional impact of medical error involvement on physicians: A call for leadership and organizational accountability. Swiss Medical Weekly. 2008 Oct 24. [Epub ahead of print]

The evidence indicates that many physicians involved in medical errors respond with serious emotional distress that may also lead to future suboptimal patient care and error. The authors suggest that, given the significant burden on physician well-being and performance associated with medical errors, health care institutions and clinical leaders have to take accountability andneed to provide staff with formal and informal systems of support.

Rao H, Sutton R. The ergonomics of innovation. McKinsey Quarterly. 2008;4:131-141.

This article traces the history and ideas that led to IHI’s 100,000 Lives Campaign, which ran from December 2004 to June 2006. The authors are especially interested in the unique structure and mobilizing strategies that enabled so many hospitals to participate in and take advantage of this first of its kind national initiative to prevent unnecessary deaths in US hospitals.