To Do No Harm

Julianne M. Morath is the chief operating officer and vice president of care delivery of Children's Hospitals and Clinics in Minneapolis - St. Paul, Minnesota. She is a board member of the National Patient Safety Foundation in Chicago, Illinois. Joanne E. Turnbull, RN, MS, is a well-known writer and speaker on the subject of patient safety. Until 2001 she was the executive director of the National Patient Safety Foundation.

• Foreword ixLucian L. Leape Preface xvAcknowledgments xxiiiThe Authors xxviiIntroduction 11 Declare Patient Safety Urgent and a Priority 122 Error and Harm in Health Care 233 Understanding the Basics of Patient Safety 444 Assume Executive Responsibility 715 Import New Knowledge and Skills 966 Install a Blameless Reporting System 1207 Assign Accountability 1488 Align External Controls and Reform Education 1819 Accelerate Change For Improvement 20410 The End of the Beginning 234References 245Glossary 255Appendixes1 Checklist for Assessing Institutional Resilience 2792 Creating De-Identified Case Studies for Dissemination 2833 Medical Accidents Policy: Reporting and Disclosure,Including Sentinel Events 2854 Medication Safety Team Feedback Form 2955 Patient Safety Workplan 2976 Safety Learning Report 3007 Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety 3038 Complexity Lens Reflection 3089 A Brief Look at Gaps in the Continuity of Care 31110 A Brief Look at the New Look in Complex System Failure, Error, and Safety 31311 A Reminder on Every Chart 31512 List of Serious Reportable Events in Health Care 31613 Statement of Principle: Talking to Patients About Health Care Injury 32114 VHA Patient Safety Organizational Assessment 322Additional Readings 331Resources 335Index 345