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Written Statement

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National Summit on Medical Errors and Patient Safety Research

Panel 4: Reporting Issues and Learning Approaches

Testimony of Lucy A. Savitz, Ph.D., MBA, Assistant Professor, Health Policy and Administration and Obstetrics and Gynecology, Schools of Public Health and Medicine, University of North Carolina at Chapel Hill (UNC)


The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summitís goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs.

Individuals were selected by the Agency for Healthcare Research and Quality (AHRQ) to testify at the summit as members of the witness panels. Each submitted written statements for the record before the event, documenting key issues that they confront with regard to patient safety as well as questions to be researched. Other applicants were invited to submit written statements.

Disclaimer and Copyright Statements


Key Research Issues & Suggested Questions. Research has been conducted which documents: (1) under-reporting of medical errors; (2) that reductions in errors can be made with reporting and/or surveillance systems; and (3) problems in the definition and scope of medical errors. Based on this preliminary understanding, we need to begin to address important these issues related to reporting and continued learning efforts by:

  • Establishing a common definition or set of definitions for what constitutes a preventable adverse medical event (AME) that goes beyond mortality, medication, and procedural errors to include technological failures and human errors.
  • Define the appropriate scope (i.e., individual vs. system perspective) within which to consider preventable AMEs.
  • Understand the opportunities and limitations of comparative analyses, benchmarking, and reporting of this information.

Establishing a common foundation for this research is critical to providing the incremental research base that will improve our understanding and yield practical and relevant solutions to the problem and prevention of AMEs and their respective patient consequences. Examples of key research questions that emanate from a systems perspective of AMEs include:

  1. What are the cultural issues involved in removing the "cloak of silence" in AME reporting? Related to this are such questions as:
    • How can we create the cultural atmosphere that allows us to learn from near misses, latent errors, and system failures?
    • Can we create an open forum for best practice sharing across systems of care?

  2. What are the unintended consequences of enhanced AME data capture (e.g., individual/group accountability, malpractice liability, financial cost of implementation, cost-benefit)?
  3. How can we use collected AME information to prevent future AMEs through the development of models that provide threshold alerts for patients and/or departments at risk?
  4. Can we develop a standardized method for accurately tracking and monitoring the influence on patient outcomes and financial costs that result from intervention initiatives?
  5. What are the implications of financial cutbacks in staffing and resource allocation for patient safety (e.g., staffing mix substitutions of LPN/CNAs for RNs, staffing reductions that increase the patient/FTE ratios)?
  6. How can we stimulate creation of a comparative evaluative study research base for best practices in interventions aimed at AME prevention?
  7. Can we create useful tools to promote the transfer of applied research into practice in order to achieve enhanced patient outcomes?

Research & Learning Approaches. It will be important to pool resources across the fragmented health care industry to address common research questions such as these. Given the information technology incompatibilities and variations in information capture (over time and in comprehensiveness), we will need to identify lead systems with sophisticated, data warehouses to collaborate in the development of models to generate the necessary, incremental evidence that is critical to shared learning and ultimate prevention of avoidable AMEs. Implementation of specific interventions should be evidence-based, much the same as we are currently expecting of clinical process innovations and medical practice, because the costs, risks, and administrative burden are likely to be significant. Along these lines, we will need to pilot developed interventions and report on their effectiveness via soundly executed evaluation studies that can be published in the peer review literature. In order for this growing body of evidence to have a real influence on interventions and ultimately improved patient safety, it will be necessary to educate health care managers in the application and interpretation of such evidence.


Key Research Issues

Research has been conducted which documents: (1) the under-reporting of medical errors; (2) that reductions in errors can be made with reporting and/or surveillance systems; (3) problems in the definition and scope of medical errors. Based on this preliminary understanding, we need to begin to address important these issues related to reporting and continued learning efforts by:

  • Establishing a common definition or set of definitions for what constitutes a preventable adverse medical event (AME) that goes beyond mortality, medication, and procedural errors to include technological failures and human errors.
  • Define the appropriate scope (i.e., individual vs. system perspective) within which to considers preventable AMEs.
  • Understand the opportunities and limitations of comparative analyses, benchmarking, and reporting of this information.

Establishing a Standard Set of Definitions. Currently, research in the area of patient safety and medical errors is plagued by the pervasive problem commonly encountered by health services researchers whereby key outcomes are not consistently measured and/or modeled (e.g., quality, access). We face this same issue whether we define the scope of pertinent learning and research to be around patient safety, medical errors and/or AMEs. For the incremental progression of learning through research to have the highest value, we should agree from the outset on a clinically relevant and meaningful definition or core set of definitions. The definition can be expanded as our ability to more precisely measure through enhanced data capture and reductions in measurement error increases over time. For example, health service organizations do not necessarily have processes in place to capture all near misses and/or latent failures (i.e., those failures that are caught in time, contained, or remedied prior to the actual event that results in a negative patient outcome). This implies that the scope of the definition will be incrementally expanding over time (Figure 1 [10 KB]).

This situation can already be seen from our expanded focus beyond medication errors to encompass a larger set of patient safety issues as the human engineering and related systems perspectives prevail in extending our enhanced understanding of these complex processes. Figure 2 (11 KB) depicts the situation where system error occurs when errors at multiple levels—treatment/technology, patient characteristics, and work environment-coincide. Thus, it may be necessary to incorporate differential definitions in our explanatory models as our information technology and measurement capabilities mature.

Defining the Appropriate Scope of AMEs. Adverse medical events or AMEs are both preventable, including both individual "errors" and system failures, and non-preventable. It is often difficult to tell the difference. For example, some in-house deaths are preventable while others are a natural consequence of a patient's condition. Examples of the elements within the scope of medical events that should be appropriately considered when conducting such research include:

  • Adverse drug events.
  • Iatronogenic infections.
  • Nosocomial infections.
  • Venous thromboembolism.
  • Decubitus ulcers.
  • Patient falls.
  • Poor management of patients in extremis (e.g., unnecessary use of restraints and sedating medications).
  • Rare sentinel events (e.g., rape, kidnapping).
  • In-house death.
  • Unscheduled return to surgery.
  • Adverse device events and/or device malfunctions.

While these are important elements for discussion in defining AMEs, both preventable and non-preventable, our ability to adequately measure and capture (either written notes or electronic data entry) these events is limited at the present time.

Opportunities for Comparative Analyses, Benchmarking & Reporting. Fragmentation within the health care industry presents a myriad of health services research problems, not the least of which includes a lack of definitional standards, variation in information technology infrastructure, and lack of a national system for data reporting. Development of a set of common definitions to promote research and for health care facilities and integrated delivery systems (IDSs) to internally capture and monitor AME data will be an important beginning. Common definitional sets will pave the way for comparative analyses across facilities and/or IDSs, allow for benchmarking to ascertain industry standards and norms, and enable consistent reporting to meet the industry's needs for planned national data quality and regulatory reporting requirements (e.g., NCQA, JCAHO.

Suggested Research Questions from a Systems Perspective

Establishing a common foundation for patient safety research is critical to providing the incremental research base that will improve our understanding and yield practical and relevant solutions to the problem of AMEs and their respective patient consequences. Examples of key research questions that emanate from a systems perspective of AMEs include:

  1. What are the cultural issues involved in removing the "cloak of silence" in AME reporting? Related to this are such questions as:
    • How can we create the cultural atmosphere that allows us to learn from near misses, latent errors, and system failures?
    • Can we create an open forum for best practice sharing across systems of care?

  2. What are the unintended consequences of enhanced AME data capture (e.g., individual/group accountability, malpractice liability, financial cost of implementation, cost-benefit)?
  3. How can we use collected AME information to prevent future AMEs through the development of models that provide threshold alerts for patients and/or departments at risk?
  4. Can we develop a standardized method for accurately tracking and monitoring the influence on patient outcomes and financial costs that result from intervention initiatives?
  5. What are the implications of financial cutbacks in staffing and resource allocation for patient safety (e.g., staffing mix substitutions of LPN/CNAs for RNs, staffing reductions that increase the patient/FTE ratios)?
  6. How can we stimulate creation of a comparative, evaluative study, research base for best practices in interventions aimed at AME prevention?
  7. Can we create useful tools to promote the transfer of applied research into practice in order to achieve enhanced patient outcomes?

Research & Learning Approaches

To address the complex issues surrounding patient safety and medical errors together with inherent reporting and measurement problems, we will need to consider three areas that will enhance our research and learning capabilities. These are:

  1. Identify a mechanism to pool IDS resources to address these research issues.
  2. Identify mature IDSs/facilities that are willing to take the lead in developing and testing AME prevention models and tools given their sophisticated electronic data warehouses.
  3. Pilot best practice interventions that promote patient safety and provide reliable and valid results from well designed and executed evaluation studies.
  4. Educate health care managers in the application and interpretation of such evidence.
  5. Permit the application of research in health care administration and clinical practice via the development of management tools.

It will be important to create a mechanism for pooling IDS resources across the fragmented health care industry to address common research questions such as these. Focused task orders issued to recipients of the "Accelerating the Cycle of Research in Integrated Delivery Systems" awards or collaborating with established consortia such as the Center for Health Management Research/Center for Organized Delivery Systems (Drs. Howard Zuckerman and Steve Shortell, Co-Directors) may provide an important first step in pooling necessary resources to address the research and learning needs of the field. Given the information technology incompatibilities and variations in information capture (over time and in comprehensiveness), we will need to identify mature IDSs/facilities with sophisticated data warehouses to take a lead in the development of AME prevention models that can be used to generate the necessary, incremental evidence and tools that are critical to shared learning and ultimately the prevention of AMEs. Implementation of specific interventions should be evidence-based, much the same as we expect of clinical process innovations and medical practice, because the costs, risks, and administrative burden are likely to be significant. Shared best practice dissemination activities have already begun (e.g., American Hospital Association). Along these lines, we will need to pilot developed interventions that promote patient safety and report on their effectiveness via soundly executed evaluation studies that can be published in the peer review literature so that best practices can be identified, shared, and adopted across the industry. Accumulated data from these trials in various types of health care settings can begin to yield necessary information for the adoption of national standards for reliable comparisons that don't unnecessarily burden a financially constrained industry.

In order for this growing body of evidence to have a real influence on interventions and ultimately improved patient safety, it will be necessary to educate managers in the application and interpretation of such evidence. Development of a measure that can be used as a patient management tool to predict which patients are at greatest risk for system error and a management tool to support resource allocation decisions would be a valuable extension of focused research and learning in the area of patient safety. Development of such tools would permit the application of research in health care administration and clinical practice.

Acknowledgements

The author would like to acknowledge the intellectual contributions of the following individuals, who have been instrumental in developing the ideas contained herein: Dr. Kerry Kilpatrick and Diane Kelly, RN, MBA, from the UNC Department of Health Policy and Administration; Ms. Patrice Spath an independent nursing consultant in Oregon; Dr. Brent James, Mr. Stanley Pestotnik, Dr. John Burke from Intermountain Health Care; Dr. Kathy Lohr from the Research Triangle Institute and the UNC School of Public Health Program on Health Outcomes; and Dr. Daniel Risser, a social psychologist at Dynamics Research Corporation. Additionally, the support and encouragement provided by Drs. William Roper, Timothy Carey, and Sue Tolleson-Rinehart through the UNC School of Public Health Program on Health Outcomes are appreciated. Finally, the author particularly appreciates the mentorship, learning opportunities, insights, and intellectual stimulation provided by Dr. Arnold Kaluzny in the UNC Department of Health Policy and Administration and Dr. Howard Zuckerman from the University of Washington and Director of the Center for Health Management Research.

Select Bibliography

Albers, GW, VE Bates, WM Clark et al.: "Intravenous Tissue-Type Plasminogen Activator for Treatment of Acute Stroke," JAMA, 283(9):1145-1150, 2000.

Berwick, DM: "A Primer on Leading the Improvement of Systems," British Medical Journal, 312(7031):619-622, 1996.

Berwick, DM: "Developing and Testing Changes in Delivery of Care," Annals of Internal Medicine, 128(8):651-656, 1998.

Berwick, DM: "Sounding Board: Continuous Improvement as an Ideal in Health Care," The New England Journal of Medicine, 320(1):53-56, 1989.

Berwick, D. M., Godfrey, A.B., & Reossner, J. Curing Health Care: New Strategies for Quality Improvement. San Francisco: Jossey-Bass Inc, 1990.

Berwick, DM: "The Double Edge of Knowledge," JAMA, 266(6):841-842, 1991.

Berwick, DM: "A Primer on Leading the Improvement of Systems," British Medical Journal, 312(7031):619-622, 1996.

Berwick, DM: "The Total Customer Relationship in Health Care: Broadening the Bandwidth," Journal on Quality Improvement, 23(5):245-250, 1997.

Berwick, DM, LL Leape: "Reducing Errors in Medicine," British Medical Journal, 319:136-7, 1999.

Casarett, D, C Helms: "System Errors versus Physicans' Errors: Finding the Balance in Medical Education," Academic Medicine, 74(1):19-22, 1999.

CDC (National Center for Health Statistics): Births and Deaths: Preliminary Data for 1998, National Vital Statistics Reports. 47(25): 6, 1999.

Chassin, MR: "Is Health Care Ready for Six Sigma Quality?," Milbank Quarterly, 76(4):565-591, 1998.

Charns, MP, JV Stoelwinder: "Coordination and Patient-unit Effectiveness: A Study of Organizational Factors Affecting Patient Care," paper presented to annual meeting of Academy of Management, 1980.

Charns, MP, LJS Tewksbury: Collaborative Management in Health Care, Implementing the Integrative Organization, San Francisco, CA: Jossey-Bass, 1993.

Chopra, V et al.: "Reported Significant Observations During Anesthesia," British Journal of Anesthesia, 68(1):13-17, 1992.

Classen, DC, SL Pestotnik, RS Evans et al.: "Computerized Surveillance of Adverse Drug Events in Hospital Patients," JAMA, 266(20):2847-2851, 1991.

Classen, DC, SL Pestotnik: "The Computer-Based Patient Record: An Essential Technology for Hospital Epidemiology, " Chapter 9 in Hospital Epidemiology and Infection, Mayhall, GC, (Editor), Williams & Wilkins, Baltimore, 1996.

Classen, DC, SL Pestotnik, RS Evans et al.: "Adverse Drug Events in Hospitalized Patients: Excess Length of Stay, Extra Costs, and Attributable Mortality," JAMA, 277(4):301-306, 1997.

Classen, DC, RS Evans, SL Pestotnik et al.: "The Timing of Prophylactic Administration of Antibiotics and the Risk of Surgical-Wound Infection," New England Journal of Medicine, 326:281-286, 1992.

Cook, TD, DT Campbell: Quasi-Experimentation: Design & Analysis Issues for Field Settings, Boston: Houghton Mifflin Company, 1979.

Cook, RI, DD Woods: "Operating at the Sharp End: The Complexity of Human Error," in MS Bogner (Editor), Human Error in Medicine, Hinsdale, NJ: Lawrence Erlbaum, 1994.

Donabedian, A: "Evaluating Quality of Medical Care," Milbank Quarterly, 14:166-203, 1966.

Dorner, D: The Logic of Failure, Recognizing and Avoiding Error in Complex Situations, Reading, MA: Perseus Books, 1996.

Duke, GJ, PT Morley, DJ Cooper et al.: "Management of Severe Trauma in Intensive Care Units and Surgical Wards," MJA, 170:416-419, 1999.

Evans, RS, SL Pestotnik, DC Classen et al.: "Development of an Automated Antibiotic Consultant," M.D. Computing, 10(1):17-22, 1993.

Evans, RS, SL Pestotnik, DC Classen et al.: "A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents," The New England Journal of Medicine, 338:232-238, 1998.

Evans, RS, DC Classen, SL Pestotnik et al.: "Improving Empiric Antibiotic Selection Using Computer Decision Support," Arch Internal Medicine, 154:878-884, 1994.

Feinstein, AR: "System, Supervision, Standards, and the 'Epidemic' of Negligent Medical Errors," Archives of Internal Medicine, 157:1285-1289, 1997.

Feldman, SE, DW Roblin: "Medical Accidents in Hospital Care: Applications of Failure Analysis to Hospital Quality Appraisal," Journal on Quality Improvement, 23(11):567-580, 1997.

Fischer, G et al.: "Adverse Events in Primary Care Identified from a Risk-Management Database," J Fam Practice, 45(1):40-46, 1997.

Flood, AB, J Zinn, SM Shortell, WR Scott: "Organizational Performance: Managing for Efficiency and Effectiveness," in SM Shortell and A Kaluzny (Editors), Healthcare Management: Organizational Design and Behavior, 4th Edition, Albany, NY: Delmar, 2000.

Freudenheim, M: "Corrective Medicine," Technology Section, New York Times, http://www.nytimes.com/library/tech/00/02/biztech/articles/03hopsital.html, February 3, 2000.

Grant, RS: "To the Members of the Nursing Community," Nursing Management, 1097, 1997.

Haugh, R: "To the Rescue," Hospitals and Health Networks, April:45-48, 2000.

Hinsdale, JG, JO Wyatt III, L Stapes: "Change in Morbidity Patterns after Adoption of the American College of Surgeons Complication Coding System in a Regional Trauma Center: Results of a Prospective Study," The Journal of Trauma: Injury, Infection, and Critical Care, 44(5):821-826, 1998.

James, BC: Quality Management for Health Care Delivery. Chicago: Hospital Research and Educational Trust, 1989.

James, BC: Personal e-mail exchange with Dr. Lucy Savitz, February 28, 2000.

Jervis, R: System Effects, Princeton, NJ: Princeton University Press, 1997.

Kaluzny, AD, J Barnsley: "Organizational Indicators of Quality," Health Matrix, 6(2):3-7, 1988.

Kaluzny, AD: "Revitalizing Decision Making at the Middle Management Level," Hospital and Health Services Administration, 34(1):39-51, 1989.

Kaluzny, AD: "The Role of Management in Quality Assurance," Quality Review Bulletin, 16(4):134-137, 1990.

Katzan, IL, AJ Furlan, LE Lloyd et al.: "Use of Tissue-Type Plasminogen Activator for Acute Ischemic Stroke," JAMA, 283(9):1151-1158, 2000.

Kelly, DL: "Systems Thinking: A Tool for Organizational Diagnosis in Healthcare," Chapter 10 in Making It Happen, Stories from Inside the New Workplace, Compiled from The Systems Thinker Newsletter, Waltham, MA: Pegasus Communications, Inc., 1999.

Kohn, LT, JM Corrigan, MS Donaldson (Editors): To Err is Human, Building a Safer Health System, National Academy Press, Washington, DC, 1999.

Kovner, AR, JJ Elson, J Billings: "Evidence-Based Management," Frontiers of Health Services Management, 16(4):3-24, 2000.

Krulewitz, A: "Rash Decisions," Arch Internal Medicine, 158:191, 1998.

Lesar, TS, BM Lomaestro, H Pohl: "Medication-Prescribing in a Teaching Hospital: A 9-Year Experience," Arch Internal Medicine, 156(X):1569-76, 1997.

Leape, LL: "The Nature of Adverse Events in Hospitalized Patients," NEJM, 324(6):377-384, 1991.

Leape, LL: "Error in Medicine," JAMA, 272(23):2-15, 1994.

Leape, LL: "A System Analysis Approach to Medical Error," Journal of Evaluation in Clinical Practice, 3(3):213-222, 1997.

Leape, LL et al.: Reducing Adverse Drug Events, Boston, MA: Institute for Healthcare Improvement, 1998.

Levenson, D: "White House Error Reduction Program Does Little to Quiet Hospitals' Concerns," AHA News, 36(8):1, February 28, 2000.

Levenson, D: "IOM Report on Medical Errors Sparks Powderkeg of Media Furor, Public Fear," AHA News, 35(47):1, December 6, 1999.

Liang, BA: "Error in Medicine: Legal Impediments to U.S. Reform," Journal of Health Politics, Policy and Law, 24(1):27-58, 1999.

Lohr, KN: "How Do We Measure Quality?," Health Affairs, 16(3):22-25, 1997.

Major, JW, JE Ibrahim et al.: "The Extraction of Quality-of-Care Clinical Indicators from State Health Department Administrative Databases," MJA, 170:420-424, 1999.

Matz, R: "Legal Lever for Improving Patient Care," Arch Internal Medicine, 158:191, 1998.

McCormack, EJ: Human Factors in Engineering and Design, Fourth Edition, McGraw-Hill, Inc., New York, 1976.

Mohr, JP: "Thrombolytic Therapy for Ischemic Stroke," JAMA, 283(9):1189-1191, 2000.

Murphy, EC, S Ruch, J Pepicello et al.: "Managing an Increasingly Complex System," Nursing Management, 28(10):33-36,38, 1997.

Nuland SB: "The Hazards of Hospitalization," The Wall Street Journal, December 2, 1999.

O'Reilly, C. Corporations, Culture, and Commitment: Motivation and Social Control in Organizations. California Management Review 31(4), Summer 1989, 9-25.

Pestotnik, SL, RS Evans, JP Burke et al.: "Therapeutic Antibiotic Monitoring: Surveillance Using a Computerized Expert System," The American Journal of Medicine, 88:43-48, 1990.

Pestotnik, SL, DC Classen, RS Evans et al.: "Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support: Clinical and Financial Outcomes," Annals of Internal Medicine, 124(10):884-890, 1996.

Pestotnik, SL: Personal e-mail exchange with Dr. Lucy Savitz, April 20, 2000.

Reason, JT: Managing the Risks of Organizational Accidents, Ashgate Publishing, Ltd, Aldershot, England, 1997.

Reed, L, MA Blegan, CS Goode: "Adverse Patient Occurrences as a Measure of Nursing Care Quality," J Nurs Admin, 28(5):62-69, 1998.

Risser, DT, MM Rice, ML Salisbury et al.: "The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department," Annals of Emergency Medicine, 34(3):373-383, 1999.

Risser, DT: Personal telephone conversation with Dr. Lucy Savitz, March 23, 2000.

Runciman, WB, SC Helps, EJ Sexton et al.: "A Classfication for Incidents and Accidents in the Health-Care System," J Qual Clin Pract, 18:199-211, 1998.

Savitz, LA, AD Kaluzny, D Kelly: "A Life Cycle Model for Continuous Clinical Process Innovation," Journal of Healthcare Management, in press, 45(5), 2000.

Savitz, LA, AD Kaluzny: "Assessing the Implementation of Clinical Process Innovations," Journal of Healthcare Management, in press, 45(6), 2000.

Shortell, SM, JL O'Brien, JM Camran et al.: "Assessing the Impact of Continuous Quality Improvement/Total Quality Management: Concept Versus Implementation," Health Services Research, 30(2):377-401, 1995b.

Shortell, SM, RH Jones, AW Rademaker, et al.: "Assessing the Impact of Total Quality Management and Organizational Culture on Multiple Outcomes of Care for Coronary Artery Bypass Graft Surgery Patients, Medical Care, 38(2):207-217, 2000.

Smetzer, JL, MR Cohen, DP Vogel: "Medication Errors: Integrating Individual and System Accountability," American Journal of Health-System Pharmacy, 56(12):1263, 1999.

Spath, PL (Editor): Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, Jossey-Bass Publishers, San Francisco, 2000.

Steinberg, H: "Outspoken Criticism Enhances Medical Education," Arch Internal Medicine, 158:100, 1998.

University HealthSystem Consortium (UHC): "The Effect of Nurse Staffing Levels and Skill Mix on Patient Outcomes: A Review of the Literature," University HealthSystem Consortium website, http://www.uhc.edu/members/councils/nursingdoc/quality.html, August 2, 1999.

Vaughan, D: The Challenger Launch Decision, Risky Technology, Culture, and Deviance at NASA, Chicago, IL: The University of Chicago Press, 1996.

Veney, JE, AD Kaluzny: Evaluation and Decision Making for Health Services, 3rd Edition, Ann Arbor, MI: Health Administration Press, 1999.

Vincent, C, N Stanhope, M Crowley-Murphy: "Reasons for Not Reporting Adverse Incidents: An Empirical Study," Journal of Evaluation in Clinical Practice, 5(1):13-21, 1999.

Wears RL, LL Leape: "Human Error in Emergency Medicine," Annals of Emergency Medicine, 34(3):370-372, 1999.

Weiner, BJ, JA Alexander, SM Shortell: Leadership for Quality Improvement in Health Care: Empirical Evidence on Hospital Boards, Managers and Physicians. Medical Care Research and Review, 53(4), December 1996, pp. 397-416.

Young, GJ, MP Charns, GL Barbour: "Best Practices for Managing Surgical Services: The Role of Coordination," Health Care Management Review, 22(4):72-81, 1997.

Young, GJ, MP Charns, K Desai, et al.: "Patterns of Coordination and Clinical Outcomes: A Study of Surgical Services," Health Services Research, 33(5):1211-1236, 1998.

Current as of September 2000


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