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19. Feely, John; Moriarty, Siobhan; O'Connor, Patricia. Stimulating Reporting of Adverse Drug Reactions by Using a Fee. BMJ. 300:22–23, 1990.

20. FDA, ''Managing the Risks from Medical Product Use," 1999.

21. Brewer and Colditz, 1999.

22. Farrington, Paddy; Pugh, Simon; Colville, Alaric, et al. A New Method for Active Surveillance of Adverse Events from Diphtheria/Tetanus/Pertussis and Measles/Mumps/Rubella Vaccines. Lancet. 345(8949):567–569, 1995.

23. Nagel, David C., "Human Error In Aviation Operations," in D.C. Nagel and E.L. Wiener (eds.), Human Factors in Aviation, eds., Orlando, FL: Academic Press, Inc., 1988.

24. Brewer and Colditz, 1999.

25. Medication Error Prevention—Potassium Chloride. JCAHO Sentinel Event Alert, Issue One, Oakbrook Terrace, Illinois: 1998.

26. Adapted from work by JCAHO based on presentation by Margaret VanAmringe to the Subcommittee on Creating an External Environment for Quality in Health Care, June 15, 1999, Washington, D.C.

27. Nichols, Len M. and Blumberg, Linda J. A Different Kind of "New Federalism"? The Health Insurance Portability and Accountability Act of 1996. Health Affairs. 17(3):25–42, 1998.

28. Billings, Charles, presentation to Subcommittee on Creating an External Environment for Quality, January 29, 1999.

Front Matter (R1-R24)

Executive Summary (1-16)

1 A Comprehensive Approach to Improving Patient Safety (17-25)

2 Errors in Health Care: A Leading Cause of Death and Injury (26-48)

3 Why Do Errors Happen? (49-68)

4 Building Leadership and Knowledge for Patient Safety (69-85)

5 Error Reporting Systems (86-108)

6 Protecting Voluntary Reporting Systems from Legal Discovery (109-131)

7 Setting Performance Standards and Expectations for Patient Safety (132-154)

8 Creating Safety Systems in Health Care Organizations (155-204)

A Background and Methodology (205-209)

B Glossary and Acronyms (210-214)

C Literature Summary (215-253)

D Characteristics of State Adverse Event Reporting Systems (254-265)

E Safety Activities in Health Care Organizations (266-272)

Index (273-287)