• Section 15. Footnotes

    [1] Institute of Medicine, To Err is Human: Building a Safer Health System [Website] accessed January 10, 2016. https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

    [2] Institute of Medicine, To Err is Human: Building a Safer Health System [Website] accessed January 12, 2016. https://iom.nationalacademies.org/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

    [3] The Leapfrog Group, About Leapfrog [Website] January 12, 2016. http://www.leapfroggroup.org/about_leapfrog

    [4] The Leapfrog Group, About Leapfrog [Website] January 12, 2016. http://www.leapfroggroup.org/about_leapfrog

    [5] The Leapfrog Group, Hospital Errors are the Third Leading Cause of Death in U.S., and New Hospital Safety Scores Show Improvements Are Too Slow [Website] January 12, 2016.  http://www.hospitalsafetyscore.org/newsroom/display/hospitalerrors-thirdleading-causeofdeathinus-improvementstooslow

    [6] The Leapfrog Group, Errors, Injuries, Accidents, Infections [Website] Accessed January 12, 2016. http://www.hospitalsafetyscore.org/what-is-patient-safety/errors-injuries-accidents-infections

    [7] The Leapfrog Group, The Leapfrog Group Fact Sheet [Website] Accessed January 12, 2016. http://www.leapfroggroup.org/about_leapfrog/leapfrog-factsheet

    [8] Agency for Healthcare Research and Quality, Understanding Medical Errors [Website] Accessed January 11, 2016. http://archive.ahrq.gov/quic/report/mederr4.htm

    [9] U.S. Food and Drug Administration, What is a Serious Event [Website] Accessed January 12, 2016. http://www.fda.gov/medwatch/report/DESK/advevnt.htm

    [10] National Patient Safety Foundation, RCA2 Improving Root Cause Analyses and Actions to Prevent Harm  [Website] Accessed January 11, 2016. https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/PDF/RCA2_v2-online-pub_010816.pdf

    [11] The Joint Commission, Sentinel Events [Website] January 12, 2016. http://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf

    [12] U.S. Food and Drug Administration, Med error reports to FDA show a mixed bag [Website] accessed January 12, 2016. http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm

    [13] The Joint Commission, Hospital National Patient Safety Goals [Website] January 12, 2016. http://www.jointcommission.org/assets/1/6/2016_NPSG_HAP.pdf

    [14] U.S. Food and Drug Administration, Catheter-associated Urinary Tract Infections [Website] accessed January 10, 2016. http://www.cdc.gov/HAI/ca_uti/uti.html

    [15] The Joint Commission, Managing risk during transition to new ISO tubing connector standards [Website] January 12, 2016. http://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf

    [16] The Joint Commission, About The Joint Commission [Website] January 11, 2016. https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/PDF/RCA2_v2-online-pub_010816.pdf

    [17] The Joint Commission, About The Joint Commission [Website] January 11, 2016. http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx

    [18] The Joint Commission, Sentinel Events [Website] January 11, 2016. http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf

    [19] The Joint Commission, About The Joint Commission [Website] January 11, 2016. http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx

    [20]  Joint Commission on Accreditation of Healthcare Organizations, Summary Data of Sentinel Events Reviewed by The Joint Commission [Website] Accessed January 11, 2016. http://www.jointcommission.org/assets/1/18/2004-2015_3Q_SE_Stats-Summary.pdf

    [21] Joint Commission on Accreditation of Healthcare Organizations, National Patient Safety Goals [Website] Accessed January 12, 2016. http://www.jointcommission.org/assets/1/6/2016_NPSG_AHC.pdf

    [22] The Leapfrog Group, The Leapfrog Group Fact Sheet [Website] Accessed January 12, 2016. http://www.leapfroggroup.org/about_leapfrog/leapfrog-factsheet

    [23] Agency for Healthcare Research and Quality, Safety Culture [Website] Accessed January 12, 2016. https://psnet.ahrq.gov/primers/primer/5

    [24] Brigham and Women’s Faulkner Hospital, Safety Culture Survey Results - Patient hand offs and non-punitive response to errors [Website] Accessed January 12, 2016. http://www.brighamandwomensfaulkner.org/about-us/general-information/bwfh-news/Safety-Culture-Survey-Results-Patient-hand-offs-and-non-punitive-response-to-errors.aspx#.Vp-qyZMrKN9

    [25] Agency for Healthcare Research and Quality, Five Steps to Safer Health Care [Website] Accessed January 10, 2016. http://www.ahrq.gov/patients-consumers/care-planning/errors/5steps/index.html

    [26] Medication Errors, The US Food and Drug Administration [Website] Accessed January 10, 2016. http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default.htm

    [27] The Leapfrog Group, Despite Improvement, New Report Reveals Technology to Prevent Medication Errors Fails Too Often [Website] Accessed January 12, 2016. http://www.leapfroggroup.org/policy_leadership/leapfrog_news/5268377

    [28] Feature Article: Medication Errors - Volume 1, Number 4, Summer 2008, The US Food and Drug Administration [Website] Accessed January 10, 2016. http://www.fda.gov/Drugs/DrugSafety/DrugSafetyNewsletter/ucm120618.htm

    [29] Feature Article: Medication Errors - Volume 1, Number 4, Summer 2008, The US Food and Drug Administration [Website] Accessed January 12, 2016.

    [30]  Academy of Nutrition and Dietetics, Patient Care [Website] Accessed January 12, 2016. http://www.eatrightpro.org/resources/practice/patient-care

    [31] Yale Journal of Health Policy, Law, and Ethics, National Survey of Medical Error Reporting Laws [Website] Accessed January 12, 2016. http://www.yale.edu/yjhple/issues/vix-i1-win09/docs/feature.pdf

    [32] State of Florida, Florida Statutes [Website] Accessed January 12, 2016. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0395/0395.html

    Section 14. About the Author