Engaging in ongoing employee training in error detection, analysis, and reduction.
Implementing procedures for analyzing errors and providing feedback to direct-care workers.
Instituting rewards and incentives for error reduction.
Recommendation 7-2. The National Council of State Boards of Nursing, in consultation with patient safety experts and health care leaders, should undertake an initiative to design uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, along with guidelines for their application by state boards of nursing and other state regulatory bodies having authority over nursing.
Recommendation 7-3. Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by HCOs for internal use or shared with others solely for purposes of improving safety and quality.
Augustine C, Weick K, Bagian J, Lee C. 1999. Predispositions toward a culture of safety in a large multi-facility health system. Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care Conference held at Rancho Mirage, CA. Chicago, IL: National Patient Safety Foundation. Pp. 138–141.
Bagian JP, Gosbee JW. 2000. Developing a culture of patient safety at the VA. Ambulatory Outreach Spring:25–29.
Bagian JP, Lee C, Gosbee J, Derosier J, Stalhandske E, Eldridge N, Williams R, Burkhardt M. 2001. Developing and deploying a patient safety program in a large health care delivery systems: You can’t fix what you don’t know about. The Joint Commission Journal on Quality Improvement 27(10):522–532.
Banister G, Butt L, Hackel R. 1996. How nurses perceive medication errors. Nursing Management 27(1):31–34.
Barach P, Small S. 2000. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal 320:759–763.
Bigley G, Roberts K. 2001. Structuring temporary systems for high reliability. Academy of Management Journal 44:1281–1300.
Carnino A, Director, Division of Nuclear Installation Safety, International Atomic Energy Agency. Undated. Management of Safety, Safety Culture and Self Assessment. [Online]. Available: http://www.iaea.org/ns/nusafe/publish/papers/mng_safe.htm [accessed January 15, 2003].
Cook R, Render M, Woods D. 2000. Gaps in the continuity of care and progress on patient safety. British Medical Journal 320(7237):791–794.
Cooper M. 2000. Towards a model of safety culture. Safety Science 36:111–136.
DeLong D, Fahey L. 2000. Diagnosing cultural barriers to knowledge management. Academy of Management Executive 14(4):113–127.