American Journal of Medical Quality · 2011 · 28 citations · 16 references
Health ProfessionsHealth AdministrationHealth Care ManagementHealth Services ResearchPatient SafetyRisk AssessmentHealth Care Risk ManagementOrganizational Learning In HealthcarePatient Safety OutcomesPeer AssessmentPeer ReviewSafety AssessmentHealth ImprovementsOpen Information SharingOrganizational Learning AssessmentOrganizational Learning LoopsPatient Safety LearningPatient Safety MeasurementPeer-to-peer ReviewRetrospective Record Review
Health care has primarily used retrospective review approaches to identify and mitigate hazards, with little evidence of measurable and sustained improvements in patient safety. Conversely, the nuclear power industry has used a prospective peer-to-peer (P2P) assessment process grounded in open information exchange and cooperative organizational learning to realize substantial and sustainable improvements in safety. In comparing approaches, it is evident that health care's sluggish progress stems from weaknesses in hazard identification and mitigation and in organizational learning. This article proposes creating and implementing a structured prospective P2P assessment model in health care, similar to that used in the nuclear power industry, to accelerate improvements in patient safety.
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Crossing the Quality Chasm: A New Health System for the 21st Century
BMJ · 2001 · 10.8K citations
Human error: models and management
James Reason · BMJ · 2000 · 5.4K citations · Full text
Social Sciences, Human Resource Management, Organizational Behavior +12