AHRQ. See Agency for Healthcare Research and Quality

Air Commerce Act, 411

Air Transport Association of America, 412

Aircraft carriers, communication redundancies on, 262

Alerts, generating when standards of care are not being followed, 265

AMA. See American Medical Association

American Academy of Nursing, 209

American Association of Colleges of Nursing, 207

American Association of Critical Care Nurses (AACCN), 269, 390

American College of Critical Care Medicine, 2, 93

American Health Care Association (AHCA), 43, 69, 86, 320

American Hospital Association (AHA), 132, 174, 178, 204, 243

Annual Survey of Hospitals, 200

American Institute of Architects, 269

American Medical Association (AMA), 395

American Medical Student Association, 395

American Nurses Association (ANA), 88, 148, 232

American Nurses’ Credentialing Center (ANCC), 148, 150

American Organization of Nurse Executives (AONE), 86, 120, 133–134

American Society for Training and Development (ASTD), 206–208

American Society of Health Systems Pharmacists, 241

Ames Fatigue Countermeasures Group, 415

ANA. See American Nurses Association

ANCC. See American Nurses’ Credentialing Center

Annual Survey of Hospitals, 200

Anticipatory failure analysis, 257

AONE. See American Organization of Nurse Executives

Apollo 13, 414–415

Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, 167

Phase II Final Report, 10, 182–183

ASRS. See Aviation Safety Reporting System


continual, of staffing methodologies and their relationship to patient safety, 193

of existing knowledge culture within organizations, 129–130

of patient acuity level, 184–185

of patients, 32, 34

Assistance in knowledge and skill acquisition, need to strengthen ongoing, 201–206

Association of American Medical Colleges (AAMC), 391, 395

ASTD. See American Society for Training and Development

Asynchronous messaging, 266

Attention, short-lived, 141–142

Attribution errors, fundamental, 27

Australia, error rates in, 27

“Authority gradient,” 289


of record systems, 246, 266

use of, 246–247

Aviation Human Factors Team, 412

Aviation industry, work hour regulation in, 410–413

Aviation Safety Reporting System (ASRS), 412


Back-up systems, instilling, 262–263

Balanced Budget Act of 1997, 85

Bar code medication administration (BCMA) assistance device, 241–242, 267

Barriers to effective safety cultures, 299–303

litigation and regulatory barriers, 300–303

nursing cultures fostering unrealistic expectations of clinical perfection, 299–300

Barriers to effective team development and performance, 366–368

BCMA. See Bar code medication administration assistance device

Bell, Bertand, 394

“Bell Regulations,” 393–394

Benchmarking organizational safety cultures, 308–309

Benchmarking training practices, in other industries and health care, 206–207

Benefits in addition to patient safety, 316–322

better retention of nurses and other health care workers in short supply, 317–319

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