7. Richard Pascale, Jerry Sternin, and Monique Sternin, The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems (Boston, MA: Harvard Business Press, 2010).
8. Arvind Singhal and Karen Greiner, “Do What You Can with What You Have, Where You Are Now: A Quest to Eliminate MRSA at the VA Pittsburgh Healthcare System,” Deeper Learning 1, no. 4 (2007).
9. Singhal and Greiner, “Do What You Can with What You Have,” 6.
10. Pascale, Sternin, and Sternin, The Power of Positive Deviance; Singhal and Greiner, “Do What You Can with What You Have.”
11. Singhal and Greiner, “Do What You Can with What You Have,” 12.
12. Comment on positive deviance work at the VA: The VA Pittsburgh Healthcare System’s website includes updates on its positive deviance work, but such postings ended in 2008. By the time the manuscript for this book was submitted to the publisher, nobody had responded to requests for an update on the initiative or its diffusion to other facilities.
13. Pascale, Sternin, and Sternin, The Power of Positive Deviance.
14. Noreen M. Clark et al., “Community Coalitions to Control Chronic Disease: Allies against Asthma as a Model and Case Study,” Health Promotion Practice 7, no. 2 (Supplement) (2006); G. B. LeFever, F. D. Butterfoss, and N. Vislocky, “High Prevalence of Attention Deficit Hyperactivity Disorder: Catalyst for Development of a School Health Coalition,” Family and Community Health 22, no. 1 (1999); K. M. Mack, C. S. Kelly, and A. L. Morrow, “Head Start: A Setting for Asthma Outreach and Prevention,” Community Health 22, no. 1.
15. J. A. Alexander et al., “Sustainability of Collaborative Capacity in Community Health Partnerships,” Medical Research and Review 60, no. 4 (2003); P. G. Foster-Fishman et al., “Building Collaborative Capacity in Community Coalitions: A Review and Integrative Framework,” American Journal of Community Psychology 29, no. 2241–261 (2001).
16. Clark et al., “Community Coalitions to Control Chronic Disease.”
17. Alexander et al., “Sustainability of Collaborative Capacity in Community Health Partnerships”; Foster-Fishman et al., “Building Collaborative Capacity in Community Coalitions.”
18. Comment on steps for building a community coalition: The steps in the table at the end of this chapter represent an adaptation of material that was posted on the Illinois attorney general’s website.
19. G. B. LeFever, A. P. Arcona, and D. O. Antonuccio, “ADHD among American Schoolchildren: Evidence of Overdiagnosis and Overuse of Medication,” Scientific Review of Mental Health Practice 2, no. 1 (2003); LeFever, Butterfoss, and Vislocky, “High Prevalence of Attention Deficit Hyperactivity Disorder”; G. B. LeFever et al., “Understanding ADHD Issues in a Community with a High ADHD Prevalence Rate: Parent, Teacher, and Provider Prespectives,” in 128th Annual Meeting of the American Public Health Association (Boston, MA, 2000); G. B. LeFever et al., “Parental Perceptions of Adverse Educational Outcomes among Children Diagnosed with ADHD: A Call for Improved School/Provider Collaboration,” Psychology in the Schools 39, no. 1 (2002).
20. G. B. LeFever, “Issue Brief: Increased Use of Psychiatric Drugs in American Schools” (Arlington, VA: The Lexington Institute, 2002); LeFever, Arcona, and Antonuccio, “ADHD among American Schoolchildren”; G. B. LeFever, K. V. Dawson, and A. L. Morrow, “The Extent of Drug Therapy for Attention-Deficit/Hyperactivity Disorder among Children in Public Schools,” American Journal of Public Health 89, no. 9 (1999).
21. G. B. LeFever, K. Allen, and E. A. Plasden, “Piloting a School-Wide Behavioral Intervention Study,” in 132nd Annual Meeting of the American Public Health Association (Washington, DC, 2004).
22. Gretchen LeFever Watson et al., “Shooting the Messenger: The Case of ADHD,” Journal of Contemporary Psychotherapy 44, no. 1 (2014).
23. Gretchen LeFever Watson, Andrea Powell Arcona, and David O. Antonuccio, “The ADHD Drug Abuse Crisis on American College Campuses,” Ethical Human Psychology and Psychiatry 17, no. 1 (2015).
24. S. N. Visser et al., “Trends in the Parent-Report of Health Care Provider-Diagnosed and Medicated Attention-Deficit/Hyperactivity Disorder: United States, 2003–2011,” Journal of the American Academy of Child & Adolescent Psychiatry (2013).
25. A. Schwarz, “The Selling of Attention Deficit Disorder,” New York Times, December 14, 2013; Watson, Arcona, and Antonuccio, “The ADHD Drug Abuse Crisis on American College Campuses.”
26. G. L. Watson and A. P. Arcona, “8 Ways to Respond to Student ADHD Drug Abuse,” Campus Safety, 2014; “ADHD Drug Abuse Epidemic Prompts New School Rules,” Campus Safety, May 3, 2014; Watson, Arcona, and Antonuccio, “The ADHD Drug Abuse Crises on American College Campuses.”
27. Watson, Arcona, and Antonuccio, “The ADHD Drug Abuse Crises on American College Campuses.”
28. Martin A. Makary and Michael Daniel, “Medical Error—the Third Leading Cause of Death in the US,” BMJ 353 (2016).
29. National Patient Safety Foundation, http://www.npsf.org/?page=aboutus.
30. The group did not meet all community coalition criteria in that membership was not open to the public; it was based on an application process.
31. G. B. LeFever, “Chasing Zero Events of Harm: An Urgent Call to Expand Safety Culture Work and Patient Engagement,” Nursing and Patient Care (February 2010), http://www.yoursls.com/ConnectingHospitals-Communities.pdf.
32. James L Reinertsen, Michael D. Bisgnano, and Maureen Pugh, “Seven Leadership Leverage Points for Organizational-Level Improvement in Health Care” (Cambridge, MA: Institute for Healthcare Improvement, 2008), 17.
33. National Patient Safety Foundation, “Safety Is Personal: Partnering with Patients and Families for the Safest Care,” xiii.
Chapter 7
1. Arthur Conan Doyle, The Complete Sherlock Holmes (New York: Bantam Classics, 1986).
2. George David Smith and Frederick Dalzell, Wisdom from the Robber Barons: Enduring Lessons from Rockefeller, Morgan, and the First Industrialists (New York: Basic Books, 2000).
3. Alexandra Robbins, The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (New York: Workman Publishing Company, Inc., 2015).
4. Melanie E deWit et al., “Supporting Second Victims of Patient Safety Events: Shouldn’t These Communications Be Covered by Legal Privilege?” Journal of Law, Medicine, and Ethics (Winter 2013); Stephen Pratt et al., “How to Develop a Second Victim Support Program: A Toolkit for Health Care Organizations,” Joint Commission Journal on Quality and Patient Safety 38, no. 5 (2012); Susan D. Scott, “The ‘Second Victim’ Phenomenon: A Harsh Reality of Health Care Professions,” Perpectives on Safety (May 2011), https://psnet.ahrq.gov/perspectives/perspective/102.
5. Carolyn M Clancy, “Alleviating ‘Secondary Victim’ Syndrome: How We Should Handle Patient Harm?” Journal of Nursing Care Quality 27, no. 1 (2012); Scott, “The ‘Second Victim’ Phenomenon”; Albert W. Wu et al., “Disclosure of Adverse Events in the United States and Canada: An Update, and a Proposed Framework for Improvement,” Journal of Public Health Research 2, no. 3 (2013).
6. Albert W. Wu, “Medical Error: The Second Victim: The Doctor Who Makes the Mistake Needs Help Too,” BMJ: British Medical Journal 320, no. 7237 (2000): 726–27.
7. Clancy, “Alleviating ‘Secondary Victim’ Syndrome.”
8. Pratt et al., “How to Develop a Second Victim Support Program.”
9. Jane Garbutt et al., “Reporting and Disclosing Medical Errors: Pediatricians’ Attitudes and Behaviors,” Archives of Pediatric and Adolescent Medicine 16, no. 2 (2007).
10. Robbins, The Nurses.
11. deWit et al., “Supporting Second Victims of Patient Safety Events.”
12. Samuel Gorovitz and Alasdair MacIntyre, “Toward a Theory of Medical Fallibility,” Hastings Center Report (December 1975).
13. Elizabeth A. McGlynn et al., “The Quality of Health Care D
elivered to Adults in the United States,” New England Journal of Medicine 348, no. 26 (2003).
14. Mark Ware and Michael Mabe, “The STM Report: An Overview of Scientific and Scholarly Publishing,” in The STM Report (Netherlands, 2012).
15. John P. A. Ioannidis, “Why Most Published Research Findings Are False,” PLoS Medicine 2, no. 8 (2007).
16. Shannon Brownlee, Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (New York: Bloomsbury, 2008); Sandeep Jauhar, Doctored: The Disillusionment of an American Physician (New York: Farrar, Straus, and Giroux, 2014).
17. Gorovitz and MacIntyre, “Toward a Theory of Medical Fallibility,” 13.
18. James Lyons-Weiler, in Cures vs. Profits: Successes in Translational Research (London: World Scientific, 2016).
19. D. H. Novack et al., “Changes in Physicians’ Attitudes toward Telling the Cancer Patient,” JAMA 241, no. 9 (1979).
20. Norman Hamilton, “Suicide of Nurse after Tragic Event,” Seattle Times, April 22, 2011.
21. Rosemary Gibson and Janardan Prasad Singh, Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injury Millions of Americans (Washington, DC: LifeLine Press, 2003), 104–5.
22. Malcolm Gladwell, Outliers: The Story of Success. New York: Little, Brown and Company, 2008.
23. A. Schwarz, “Drowned in a Stream of Prescriptions,” New York Times, February 2, 2013.
24. Elizabeth Simpson, “Va. Beach Psychiatrist’s License to Be Suspended,” Virginian-Pilot, October 28, 2014.
25. Megan McArdle, The Up Side of Down: Why Failing Well Is the Key to Success (New York: Penquin Books, 2015), 80.
26. McArdle, The Up Side of Down, 80.
27. McArdle, The Up Side of Down, 81.
28. McArdle, The Up Side of Down, 82.
29. Linda H Aiken et al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” Journal of the American Medical Association 288, no. 16 (2002).
30. K. Frith et al., “Nurse Staffing Is an Important Strategy to Prevent Medication Errors in Community Hospitals,” Nursing Economics 30, no. 5 (2012).
31. T. Lewis-Voepel et al., “Nursing Surveillance Moderates the Relationship between Staffing Levels and Pediatric Postoperative Serious Adverse Events: A Nested-Case Control Study,” International Journal of Nursing Studies 50, no. 7 (2012).
32. Institute for Safe Medication Practices, “Since When Is It a Crime to Be Human?” news release, 2006, http://www.ismp.org/pressroom/viewpoints/julie.asp.
33. T. Christine Kovner et al., “What Does Nurse Turnover Rate Mean and What Is the Rate?” Policy, Politics, & Nursing Practice 15, no. 3–4 (2014).
34. C. Kane, “Policy Research Perspectives—Medical Liability Claim Frequency: A 2007–2008 Snapshot of Physicians” (Chicago: American Medical Association, 2010).
35. Anupam B. Jena et al., “Malpractice Risk According to Physician Specialty,” New England Journal of Medicine 365, no. 629–36 (2011).
36. Stephanie P. Fein et al., “The Many Faces of Error Disclosure: A Common Set of Elements and a Definition,” Journal of General Internal Medicine 22, no. 6 (2007): 760.
37. P. J. Pronovost and E. Vohr, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out (New York: Penquin Group, 2010).
38. Wu et al., “Disclosure of Adverse Events in the United States and Canada.”
39. Ann Hendrich et al., “Ascension Health’s Demonstration of Full Disclosure Protocol for Unexpected Events During Labor and Delivery Shows Promise,” Health Affairs 33, no. 1 (2014).
40. T. H. Gallagher et al., “US and Canadian Physicians’s Attitudes and Experiences Regarding Disclosing Errors to Patients,” Archives of Internal Medicine 166, no. 15 (2006).
41. Wu et al., “Disclosure of Adverse Events in the United States and Canada.”
42. Fein et al., “The Many Faces of Error Disclosure.”
43. Joshua M. Liao, Eric J. Thomas, and Sigall K. Bell, “Speaking up About the Dangers of the Hidden Curriculum,” Health Affairs 33, no. 1 (2014): 169.
44. Gibson and Singh, Wall of Silence.
45. Gibson and Singh, Wall of Silence, 20.
46. Gibson and Singh, Wall of Silence, 186.
47. American Association of Colleges of Nursing, “Nursing Fact Sheet,” American Association of Colleges of Nursing, http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet.
48. Sarah E. Shannon et al., “Disclosing Errors to Patients: Perspectives of Registered Nurses,” The Joint Commission Journal on Quality and Patient Safety 35, no. 1 (2009).
49. Deanna L. Reising and Patricia N. Allen, “Protecting Yourself from Malpractice Claims,” American Nurse Today (February 2007).
50. Wu et al., “Disclosure of Adverse Events in the United States and Canada.”
51. Sorrel King, Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safer (New York: Atlantic Monthly Press, 2009); Pronovost and Vohr, Safe Patients, Smart Hospitals.
52. G. B. Hickson et al., “Factors That Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries,” Journal of the American Medical Association 267 (1992).
53. Albert W. Wu, Being Open with Patients and Families About Adverse Events, podcast audio, Medical Center Hour Being Open with Patients and Families, 2010, https://www.youtube.com/watch?v=DkYm8HFq_Vk.
54. N. Varjavand, S. Nair, and E. Gracely, “A Call to Address the Curricular Provision of Emotional Support in the Event of Medical Errors and Adverse Events,” Medical Education 46 (2012).
55. Michelle M. Mello et al., “Communication-and-Resolution Programs: The Challenges and Lessons Learned from Six Early Adopters,” Health Affairs 33, no. 1 (2014); Michelle M. Mello et al., “Implementing Hospital-Based Communication-and-Resolution Programs: Lessons Learned in New York City.”
56. Ann Hendrich et al., “Ascension Health’s Demonstration of Full Disclosure Protocol for Unexpected Events During Labor and Delivery Shows Promise”; Allen Kachalia et al., “Liability Claims and Costs before and after Implementation of a Medical Error Disclosure Program,” Annals of Internal Medicine 153, no. 4 (2010); Steve S. Kraman and Ginny Hamm, “Risk Management: Extreme Honesty May Be the Best Policy,” 131, no. 12 (1999); Pronovost and Vohr, Safe Patients, Smart Hospitals.
57. In addition to modeling how to translate hospital policy into action, the Ascension story can serve as a blueprint of how a community coalition might implement changes that it prioritizes.
58. Hendrich et al., “Ascension Health’s Demonstration of Full Disclosure Protocol for Unexpected Events During Labor and Delivery Shows Promise.”
59. Wu et al., “Disclosure of Adverse Events in the United States and Canada.”
60. Comment on including patients in patient safety investigations: All disclosure programs that are currently in operation may not explicitly invite patients to participate in the investigation; however, there is growing support for doing so because patients have the potential to offer unique insights for improvement and the process aids in their healing process.
61. Jason M. Etchegaray et al., “Structuring Patient and Family Involvement in Medical Error Event Disclosure and Analysis,” Health Affairs 33, no. 1 (2014).
62. Etchegaray et al., “Structuring Patient and Family Involvement in Medical Error Event Disclosure and Analysis.”
63. Etchegaray et al., “Structuring Patient and Family Involvement in Medical Error Event Disclosure and Analysis.”
64. deWit et al., “Supporting Second Victims of Patient Safety Events.”
65. Kachalia et al., “Liability Claims and Costs before and after Implementation of a Medical Error Disclosure Program.”
66. John K Iglehart, “Improved Safety, Eliminating Errors Top Policy Agenda,” Health Affairs 33, no.
1 (2014).
67. Allen Kachalia et al., “Greatest Impact of Safe Harbor Rule May Be to Improve Patient Safety, Not Reduce Liability Claims Paid by Physicians.”
68. David M. Studdert et al., “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation,” New England Journal of Medicine 354, no. 19 (2006).
69. David M. Studdert, Michelle M. Mello, and Troyen A. Brennan, “Medical Malpractice,” New England Journal of Medicine 350, no. 3 (2004).
70. deWit et al., “Supporting Second Victims of Patient Safety Events.”
71. Gorovitz and MacIntyre, “Toward a Theory of Medical Fallibility.”
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