Часть IV. Приложения

Главные книги и отчеты по медицинским ошибкам и ошибкам в целом

1. Agency for Healthcare Research and Quality. Advances in Patient Safety: From Research to Implementation. Rockville, MD : Agency for Healthcare Research and Quality, February 2005. AHRQ Publication Nos. 050021 (1–4).
2. Agency for Healthcare Research and Quality. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD : Agency for Healthcare Research and Quality, July 2008. AHRQ Publication Nos. 080034 (1–4).
3. Agency for Healthcare Research and Quality. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation. Rockville, MD : Agency for Healthcare Research and Quality, November 2009. AHRQ Publication No. 09(10)-0084.
4. Agency for Healthcare Research and Quality. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data from National Efforts to Make Health Care Safer. Rockville, MD : Agency for Healthcare Research and Quality. December 2016.
5. American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare. Reducing the Risks of Wrong-Site Surgery: Safety Practices from the Joint Commission Center for Transforming Healthcare Project. Chicago, IL : American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare, 2014.
6. Antonsen S. Safety Culture: Theory, Method and Improvement. Burlington, VT : Ashgate, 2009.
7. Berwick D.M. Escape Fire: Designs for the Future of Health Care. San Francisco, CA : Jossey-Bass, 2003.
8. Betsy Lehman Center for Patient Safety and Error Reduction. The Public’s Views on Medical Error in Massachusetts. Boston, MA: Harvard School of Public Health, December 2014.
9. Bosk C.L. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL : University of Chicago Press, 2003.
10. Bunting R.F. Jr, Schukman J., Wong W.B. A Comprehensive Guide to Managing Never Events and Hospital-Acquired Conditions. Washington, DC : Atlantic Information Services Inc., 2009.
11. Casey S.M. Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error. 2nd ed. Santa Barbara, CA : Aegean Publishing Company, 1998.
12. Columbia Accident Investigation Board. Report of the Columbia Accident Investigation Board, August 2003.
13. Conway J., Federico F., Stewart K., Campbell M.J. Respectful Management of Serious Clinical Adverse Events. Cambridge, MA : Institute for Healthcare Improvement, 2010.
14. Cook R.I., Woods D.D., Miller C. A Tale of Two Stories: Contrasting Views of Patient Safety. National Patient Safety Foundation at the AMA: Annenberg Center for Health Sciences, 1998.
15. Dekker S. The Field Guide to Human Error Investigations. 3rd ed. Aldershot, UK : Ashgate Publishing, 2014.
16. Dekker S. Just Culture: Balancing Safety and Accountability. 3rd ed. Boca Raton, FL : CRC Press, 2016.
17. Donaldson L. An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. London : The Stationery Office, 2000.
18. Farley D.O., Ridgely M.S., Mendel P. et al. Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System. Santa Monica, CA : RAND Corporation, 2009.
19. Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science. New York, NY : Metropolitan Books, 2002.
20. Gawande A. Better: A Surgeon’s Notes on Performance. New York, NY : Metropolitan Books, 2007.
21. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY : Metropolitan Books, 2009.
22. Gibson R., Singh J.P. Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans. Washington, DC : Lifeline, 2003.
23. Gosbee J.W., Gosbee L.L. (eds). Using Human Factors Engineering to Improve Patient Safety. 2nd ed. Oakbrook Terrace, IL : Joint Commission Resources, 2010.
24. Griffin F.A., Resar R.K. IHI Global Trigger Tool for Measuring Adverse Events. 2nd ed. IHI Innovation Series White Paper. Cambridge, MA : Institute for Healthcare Improvement, 2009.
25. Groopman J. How Doctors Think. Boston, MA : Houghton Mifflin, 2007.
26. Helmreich R.L., Merritt A.C. Culture at Work in Aviation and Medicine: National, Organizational, and Professional Influences. Aldershot, Hampshire, UK : Ashgate, 1998.
27. Hollnagel E. Safety-I and Safety-II: The Past and Future of Safety Management. Aldershot, Hampshire, England : Ashgate, 2014.
28. Hughes R.G. (ed.). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD : Agency for Healthcare Research and Quality, 2008. AHRQ Publication No. 08-0043.
29. Hurwitz B., Sheikh A. (eds). Health Care Errors and Patient Safety. Hoboken, NJ : Wiley-Blackwell, 2009.
30. Joint Commission. Getting the Board on Board: What Your Board Needs to Know About Quality and Safety. 3rd ed. Oakbrook, IL : Joint Commission, 2016.
31. Kahneman D., Slovic P., Tversky A. Judgment Under Uncertainty: Heuristics and Biases. Cambridge, England : Cambridge University Press, 1987.
32. Kahneman D. Thinking Fast and Slow. New York, NY : Farrar, Strauss and Giroux, 2011.
33. King S. Josie’s Story. New York, NY : Atlantic Monthly Press, 2009.
34. Krause T.R., Hidley J. Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture. Hoboken, NJ : Wiley, 2008.
35. Langley G.J., Moen R., Nolan K.M., Nolan T.W., Normal C.L., Provost L.P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA : Jossey-Bass, 2009.
36. Leonard M., Frankel A., Federico F., Frush K., Haraden C. (eds). The Essential Guide for Patient Safety Officers. 2nd ed. Oakbrook Terrace, IL : Joint Commission Resources, Institute for Healthcare Improvement, 2013.
37. Levinson D.R. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC : US Department of Health and Human Services, Office of the Inspector General, November 2010. Report No. OEI-06-09-00090.
38. Lucian Leape Institute at the National Patient Safety Foundation. Unmet Needs: Teaching Physicians to Provide Safe Patient Care. Boston, MA : Lucian Leape Institute at the National Patient Safety Foundation, March 2010.
39. Lucian Leape Institute at the National Patient Safety Foundation Roundtable on Consumer Engagement in Patient Safety. Safety is Personal: Partnering with Patients and Families for the Safest Care. Boston, MA : National Patient Safety Foundation, March 2014.
40. Lucian Leape Institute at the National Patient Safety Foundation. Shining a Light: Safer Health Care Through Transparency. Boston, MA : National Patient Safety Foundation, January 2015.
41. Lucian Leape Institute at the National Patient Safety Foundation. Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation’s Lucian Leape Institute. Boston, MA : Lucian Leape Institute at the National Patient Safety Foundation, May 2016.
42. Marx D. Whack-a-Mole: The Price We Pay for Expecting Perfection. Plano, TX : By Your Side Studios, 2009.
43. Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, VT : Massachusetts Coalition for the Prevention of Medical Errors, 2006.
44. Merry A., Smith A.M. Errors, Medicine, and the Law. Cambridge, England : Cambridge University Press, 2001.
45. Millenson M.L. Demanding Medical Excellence. Doctors and Accountability in the Information Age. Chicago, IL : University of Chicago Press, 1997.
46. Morrow R. Leading High-Reliability Organizations in Healthcare. Boca Raton, FL : Productivity Press, 2016.
47. Nance J.J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Boseman, MT : Second River Healthcare Press, 2008.
48. National Patient Safety Foundation. Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. Boston, MA : National Patient Safety Foundation, 2015.
49. National Patient Safety Foundation. RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA : National Patient Safety Foundation, 2015.
50. National Quality Forum. Identification and Prioritization of Health IT Patient Safety Measures. Washington, DC : National Quality Forum, February 2016.
51. National Quality Forum. Safe Practices for Better Healthcare — 2009 Update. Washington, DC : National Quality Forum, 2009.
52. Nemeth C.P. (ed.). Improving Healthcare Team Communication: Building on Lessons from Aviation and Aerospace. Burlington, VT : Ashgate Publishing, 2008.
53. Norman D.A. The Design of Everyday Things. New York, NY : Basic Books, 2002.
54. Paget M.A. Unity of Mistakes: A Phenomenological Interpretation of Medical Work. Philadelphia, PA : Temple University Press, 1993.
55. Perrow C. Normal Accidents: Living with High-Risk Technologies. With a New Afterword and a Postscript on the Y2K Problem. Princeton, NJ : Princeton University Press, 1999.
56. Pronovost P., Vohr E. Safe Patients, Smart Hospitals: How One Doctor’s Checklist can Help Us Change Health Care from the Inside Out. New York, NY : Hudson Street Press, 2010.
57. Reason J.T. Human Error. New York, NY : Cambridge University Press, 1990.
58. Reason J.T. Managing the Risks of Organizational Accidents. Aldershot, Hampshire, UK : Ashgate, 1997.
59. Reason J. The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Farnham Surrey, UK : Ashgate, 2008.
60. Reynard J., Reynolds J., Stevenson P. Practical Patient Safety. Oxford, UK : Oxford University Press, 2009.
61. Robins N.S. The Girl who Died Twice: Every Patient’s Nightmare: The Libby Zion Case and the Hidden Hazards of Hospitals. New York, NY : Delacorte Press, 1995.
62. Rogers E.M. Diffusion of Innovation. 5th ed. New York, NY : Free Press, 2003.
63. Rosenthal M.M., Sutcliffe K.M. (eds). Medical Error. What do We Know? What do We Do? San Francisco, CA : John Wiley & Sons, 2002.
64. Rozovsky F.A., Woods J.R. Jr (eds). The Handbook of Patient Safety Compliance: A Practical Guide for Health Care Organizations. San Francisco, CA : Jossey-Bass, 2005.
65. Sagan S.D. The Limits of Safety: Organizations, Accidents and Nuclear Weapons. Princeton, NJ : Princeton University Press, 1993.
66. Sanders L. Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis. New York, NY : Broadway Books, 2009.
67. Schuster P.M., Nykolyn L. Communication for Nurses: How to Prevent Harmful Events and Promote Patient Safety. Philadelphia, PA : F.A. Davis Company, 2010.
68. Sharpe V.A., Faden A.I. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. New York, NY : Cambridge University Press, 1998.
69. Shekelle P.G., Pronovost P.J., Wachter R.M. et al.; PSP Technical Expert Panel. Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria. Rockville, MD : Agency for Healthcare Research and Quality, December 2010. AHRQ Publication No. 11-0006-EF.
70. Shojania K.G., Duncan B.W., McDonald K.M., Wachter R.M. (eds). Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 from the Agency for Healthcare Research and Quality: AHRQ Publication No. 01-E058. Rockville, MD : Agency for Healthcare Research and Quality, July 2001.
71. Spath P.L. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. 2nd ed. San Francisco, CA : Jossey-Bass, 2011.
72. Stewart J.B. Blind Eye: How the Medical Establishment Let a Doctor Get Away with Murder. New York, NY : Simon & Schuster, 1999.
73. Tenner E. Why Things Bite Back: Technology and the Revenge of Unintended Consequences. New York, NY : A.A. Knopf, 1996.
74. Truog R.D., Browning D.M., Johnson J.A., Gallagher T.H. Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Baltimore, MD : Johns Hopkins University Press, 2011.
75. Ulmer C., Wolman D.M., Johns M.M.E. (eds). Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC : National Academies Press, 2008.
76. Vance J.E. A Guide to Patient Safety in the Medical Practice. Chicago, IL : American Medical Association, 2008.
77. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, IL : University of Chicago Press, 1997.
78. Vincent C. Patient Safety. 2nd ed. West Sussex, UK : Wiley-Blackwell, 2010.
79. Vincent C., Amalberti R. Safer Healthcare: Strategies for the Real World. New York, NY : Springer Open, 2016.
80. Wachter R.M., Shojania K.G. Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes. New York, NY : Rugged Land, 2004.
81. Wachter R. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York, NY : McGraw-Hill, 2015.
82. Weick K.E. Sensemaking in Organizations. Thousand Oaks, CA : Sage Publications, 1995.
83. Weick K.E., Sutcliffe K.M. Managing the Unexpected: Assuring High Performance in an Age of Complexity. 2nd ed. San Francisco, CA : John Wiley & Sons, 2007.
84. Weick K.E., Sutcliffe K.M. Managing the Unexpected: Sustained Performance in a Complex World, 3rd edition. San Francisco, CA : John Wiley & Sons, 2015.
85. Wiener E.L., Kanki B.G., Helmreich R.L. Cockpit Resource Management. San Diego, CA : Academic Press, 1993.
86. Woods D.D., Dekker S., Cook R., Johannesen L., Sarter N. Behind Human Error. 2nd ed. Burlington, VT : Ashgate, 2010.
87. Wu A.W. (ed.). The Value of Close Calls in Improving Patient Safety. Oakbrook Terrace, IL : Joint Commission Resources, 2011.
88. Wu H.W., Nishimi R.Y., Page-Lopez C.M., Kizer K.W. Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy. Washington, DC : National Quality Forum, 2005.
89. Youngberg B.J. (ed.). Principles of Risk Management and Patient Safety. Sudbury, MA : Jones Bartlett, 2011.
90. Yu A., Flott K., Fontana G., Darzi A. Patient Safety 2030. London, UK : NIHR Imperial Patient Safety Translational Research Centre, 2016.