Foreword (Lucian L. Leape).Preface.Acknowledgments.The Authors.Introduction.1. Declare Patient Safety Urgent and a Priority.2. Error and Harm in Health Care.3. Understanding the Basics of Patient Safety.4. Assume Executive Responsibility.5. Import New Knowledge and Skills.6. Install a Blameless Reporting System.7. Assign Accountability.8. Align External Controls and Reform Education.9. Accelerate Change For Improvement.10. The End of the Beginning.References.Glossary.Appendixes.1. Checklist for Assessing Institutional Resilience.2. Creating De-Identified Case Studies for Dissemination.3. Medical Accidents Policy: Reporting and Disclosure, Including Sentinel Events.4. Medication Safety Team Feedback Form.5. Patient Safety Workplan.6. Safety Learning Report.7. Stop-the-Line Policy: Authority to Intervene to Restore Patient Safety.8. Complexity Lens Reflection.9. A Brief Look at Gaps in the Continuity of Care.10. A Brief Look at the New Look in Complex System Failure, Error, and Safety.11. A Reminder on Every Chart.12. List of Serious Reportable Events in Health Care.13. Statement of Principle: Talking to Patients About Health Care Injury.14. VHA Patient Safety Organizational Assessment.Additional Readings.Resources.Index.
