Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Quality and Safety in Health Care. 2008 Aug;17(4):253-258.

The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery. The tool can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.

Berwick DM. Taming the technology beast. Journal of the American Medical Association. 2008 June 25;299(24):2898-2899.

This editorial comments on the report by van der Togt and colleagues on electromagnetic interference (EMI) from radiofrequency identification (RFID) technologies affecting other medical equipment in intensive care units such as infusion pumps, external pacemakers, and mechanical ventilators. The investigators found 22 of 34 EMI incidents were hazardous. Berwick points out that another important lesson of the study is that physicians and other health care decision makers should tame technology, not avoid it.

Denham CR. May I have the envelope please? Journal of Patient Safety. 2008 Jun;4(2):119-123.

This article introduces the idea of applying the aviation concept of performance envelopes — testing and defining the outer limits of safety — in health care. The author proposes that there are two health care safety envelopes to be considered: 1) the boundaries of caregivers (human factors) that are defined by their skills, knowledge, and human capabilities, and often impacted by fatigue, the work environment, and distractions; and 2) the system or systems that the caregiver is operating within.

Sexton JB, Paine LA, Manfuso J, et al. A check-up for safety culture in "my patient care area”. The Joint Commission Journal on Quality and Patient Safety. Nov 2007;33(11):699-703.

The two-page Culture Check-Up Tool, which takes 30 to 60 minutes to complete as a group exercise, can help clinicians recognize and fix culture problems.

Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care. 2004;13(Suppl 1):i85–i90.

Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations.

Frankel A, Gardner R, Maynard L, Kelly A. Using the Communication and Teamwork Skills (CATS) Assessment to measure health care team performance. The Joint Commission Journal on Quality and Patient Safety. Sep 2007;33(9):549-558.

Patient safety administrators, educators, and researchers are striving to understand how best to monitor and improve team skills and determine what approaches to monitoring best suit their organizations. A behavior-based tool, based on principles of crisis resource management (CRM) in nonmedical industries, was developed to quantitatively assess communication and team skills of health care providers in a variety of real and simulated clinical settings.

Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008 Apr;121(4):e927-35.

This article finds that adverse drug event (ADE) rates in hospitalized children are substantially higher than previously described, and that only a small percentage (3.7 percent) of ADEs were identified using traditional voluntary reporting methods. The authors describe how a pediatric-focused trigger tool is effective at identifying adverse drug events in inpatient pediatric populations.

Zimmerman TM, Amori G. Including patients in root cause and system failure analysis: Legal and psychological implications. Journal of Healthcare Risk Management. 2008;27(2):27-34.

The act of open disclosure of an adverse event alone may not be enough for patients or their families who are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post-event analysis allows risk management professionals to further improve their organization’s systems analysis process while empowering patients to be part of the solution. This article examines the legal and psychological considerations and provides tools for involving patients and caregivers in system failure analysis.

Shapiro E. Disclosing medical errors: Best practices from the "leading edge." Unpublished manuscript; March 2008.

Medical institutions are seeking to turn the tide of medical errors by confronting and openly admitting their mistakes, disclosing them to patients and families and throughout their institutions, investigating their causes, and using what they learn to improve processes and systems so these errors do not recur. This paper highlights the work of seven organizations to prevent and disclose medical errors, including how they’re doing it and what they’re learning in the process.

**Join the Discussion on Disclosing Medical Errors**

Conway J. Patients and families: Powerful new partners for health care and for caregivers. Healthcare Executive. 2008 Jan/Feb;23(1):60-62.

This article, the third in a series on IHI's 5 Million Lives Campaign intervention on governance leadership, focuses on key leadership strategies that can improve patient safety. The author describes engaging patients and families as partners for health care and for caregivers.