Improving Patient Safety by Taking Systems Seriously
JAMAPublished 29 January 2008
Stephen M. Shortell, Sara J. Singer
Citations102
SJR quartileQ1
SJR score5.35
SNIP10.71
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
A greater emphasis on safety over productivity and on teamwork over individual autonomy, increased standardization and simplification, and the implementation of an environment in which personnel are encouraged and feel comfortable to report errors and mistakes are needed.
Abstract
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA HomeNew OnlineCurrent IssueFor Authors Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) Podcasts Clinical Reviews Editors' Summary Medical News Author Interviews More JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA journal
Keywords
Health Professions
National Academies Press eBooksTo Err Is Human
14,096 Citations2000Institute of Medicine
A process for the preparation of prostaglandins which are known pharmaceutically active compounds and then R alpha , R omega -cyclopentenoids is described.
Public Health ReportsEstimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002
2,959 Citations2007R. Monina Klevens, Jonathan R. Edwards +5 more
HAIs in hospitals are a significant cause of morbidity and mortality in the United States and the method described for estimating the number of HAIs makes the best use of existing data at the national level.
Work StudyManaging the Unexpected: Assuring High Performance in an Age of Complexity
1,972 Citations2002
BMJ Quality & SafetyThe future vision of simulation in health care
1,832 Citations2004David M. Gaba
Using simulation to improve safety will require full integration of its applications into the routine structures and practices of health care, including professional societies, liability insurers, health care payers, and ultimately the public.
Administrative Science QuarterlyDisrupted Routines: Team Learning and New Technology Implementation in Hospitals
1,746 Citations2001Amy C. Edmondson, Richard M.J. Bohmer +1 more
Analysis of qualitative data suggests that implementation involved four process steps: enrollment, preparation, trials, and reflection, which illuminating the collective learning process among those directly responsible for technology implementation contributes to organizational research on routines and technology adoption.
Journal of Management StudiesSpeaking Up in the Operating Room: How Team Leaders Promote Learning in Interdisciplinary Action Teams
1,618 Citations2003Amy C. Edmondson
Analysis of data from 16 operating room teams learning to use a new technology for cardiac surgery found the most effective leaders helped teams learn by communicating a motivating rationale for change and by minimizing concerns about power and status differences to promote speaking up in the service of learning.
California Management ReviewWhy Hospitals Don't Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change
889 Citations2003Anita L. Tucker, Amy C. Edmondson
A dynamic model of the system in which front-line workers operate reveals an illusory equilibrium in which small process failures actually erode organizational effectiveness rather than driving learning and change in hospitals.
Critical Care MedicineDiscrepant attitudes about teamwork among critical care nurses and physicians*
767 Citations2003Eric J. Thomas, J. Bryan Sexton +1 more
Critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other, this discrepancy includes suboptimal conflict resolution and interpersonal communication skills.
JAMAThe 100 000 Lives Campaign
691 Citations2006Donald M. Berwick, David R. Calkins +2 more
The 100 000 Lives Campaign is a national initiative with a goal of saving 100 000 lives among patients in hospitals through improvements in the safety and effectiveness of health care, and proposes that US hospitals implement as many as possible of 6 highly feasible interventions.
Archives of Internal MedicineMedical Errors Involving Trainees
398 Citations2007Hardeep Singh, Eric J. Thomas +2 more
House staff are particularly vulnerable to medical errors owing to teamwork failures, especially lack of supervision, and Graduate medical education reform should focus on strengthening these aspects of training.
The Joint Commission Journal on Quality ImprovementA Framework for the Continual Improvement of Health Care: Building and Applying Professional and Improvement Knowledge to Test Changes in Daily Work
306 Citations1993Paul B. Batalden, Patricia K. Stoltz
A framework is presented that defines the new body of knowledge which, when joined with the professional knowledge of health care workers, can make continual improvement possible; and requirements for building and applying this knowledge to bring about improvement in health care organizations are given.
Health Services ResearchFair and Just Culture, Team Behavior, and Leadership Engagement: The Tools to Achieve High Reliability
298 Citations2006Allan Frankel, Michael W. Leonard +1 more
To achieve reliability, organizations need to begin thinking about the relationship between these efforts and linking them conceptually, and to achieve reliability they must be systematically and consistently implemented in an integrated fashion.
Academy of Management JournalSafety Climate in Health Care Organizations: A Multidimensional Approach
276 Citations2005Tal Katz‐Navon, Eitan Naveh +1 more
A curvilinear relationship between the levels of the perceived detailing of the safety procedures and the number of treatment errors was demonstrated and the perceived priority of safety moderated this relationship.
Journal of Management StudiesOrganizational Learning Activities in High‐hazard Industries: The Logics Underlying Self‐Analysis
245 Citations1998John S. Carroll
This paper presents an analysis of Incident Reviews in Nuclear Power Plants and Chemical Process Plants with a focus on nuclear power plants and chemical process plants.
Health Services ResearchFront‐Line Staff Perspectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems
130 Citations2008Anita L. Tucker, Sara J. Singer +2 more
An underutilized strategy for improving patient safety and staff efficiency is suggested: leveraging front-line staff experiences with work systems to identify and address operational failures.
The Joint Commission Journal on Quality and Patient SafetyClosing the Loop: Follow-up and Feedback in a Patient Safety Program
72 Citations2005Tejal K. Gandhi, Erin Graydon-Baker +3 more
Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item, however, it is the feedback to the reporter that perpetuates the influx of information and closes the loop.
The Joint Commission Journal on Quality and Patient SafetyPatient Safety Leadership WalkRounds™ at Partners HealthCare: Learning from Implementation
69 Citations2005Allan Frankel, Sarah Pratt Grillo +8 more
Patient Safety Leadership WalkRounds appears to be an effective tool for engaging leadership, identifying safety issues, and supporting a culture of safety.
QRB - Quality Review BulletinCross–Functional, Integrative Team Decision Making: Essential for Effective QI in Health Care
24 Citations1992Crayton A. Fargason, Cynthia Carter Haddock
Examples from experience with one service process--delivery of care to newborns--and techniques from the group behavior and conflict resolution literature are cited which could enhance the success of cross-functional teams in health care organizations.
SurgeryImpact of cardiac intraoperative precursor events on adverse outcomes
12 Citations2007Daniel Wong, David F. Torchiana +4 more
More detailed study of process in complex operations may lead to improved quality of care and patient safety, and special attention must be paid particularly to high risk patients and high risk precursor events.
PubMedCan your nurses stop a surgeon?
11 Citations2007Matthew Weinstock
The initiative, inspired by work at Sentara Healthcare, gives all employees the power to stop any action they think might harm a patient or co-worker and creates a work environment in which critical thinking is as routine as breathing.