SEARCH

SEARCH BY CITATION

References

  • 1
    Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 45871.
  • 2
    Australian Council for Safety and Quality in Health Care. Achieving Safety and Quality Improvements in Health Care. Sixth Report to the Australian Health Ministers’ Conference; 2005 Jul 28. Sydney: ACSQ. Available from URL: www.safetyandquality.org
  • 3
    Australian Council of Healthcare Standards (ACHS). National Report on Health Services Accreditation Performance: 2003 and 2004. Ultimo: ACHS; 2005 Jun. Available from URL: www.achs.org.au
  • 4
    Leape LL, Berwick DM. Five years after To Err is Human. What have we learned? JAMA 2005; 293: 238490.
  • 5
    Runciman WB, Edmonds MJ, Pradhan M. Setting priorities for patient safety. Qual Saf Health Care 2002; 11: 2249.
  • 6
    Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995; 21: 5418.
  • 7
    Shojania KG, Wald H, Gross R. Understanding medical error and improving patient safety in the inpatient setting. Med Clin North Am 2002; 86: 84767.
  • 8
    Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Does full disclosure of medical errors affect malpractice liability? Jt Comm J Qual Saf 2003; 29: 50311.
  • 9
    Weissman JS, Annas CL, Epstein AS, Schneider EC, Clarridge B, Kirle L et al. Error reporting and disclosure systems. Views from hospital leaders. JAMA 2005; 293: 135966.
  • 10
    Frankel A, Gandhi TK, Bates DW. Improving patient safety across a large integrated health care delivery system. Int J Qual Health Care 2003; 15 Suppl. 1: i31i40.
  • 11
    Magid DJ, Estabrooks PA, Brand DW, Raebel MA, Palen TE, Steiner JF et al. Translating Patient Safety Research into Clinical Practice. Advances in Patient Safety: From Research to Implementation. Baltimore: Agency for Healthcare Research and Quality, National Institutes of Health; 2004.
  • 12
    Bundaberg Hospital Commission of Inquiry. Terms of Reference. 2004 Oct. [accessed 2007 Mar 3] Available from URL: www.bhci.qld.gov.au/terms.htm
  • 13
    Davies G. Queensland Public Hospitals Commission of Inquiry Report. Queensland Health; 2005 Dec. Available from URL: http://qheps.health.qld.gov.au/restructurereform/docs/davies_inquiry.pdf
  • 14
    New South Wales Health Care Complaints Commission. Investigation Report, Campbelltown and Camden Hospitals, Macarthur Health Service. Sydney: New South Wales Department of Health; 2003.
  • 15
    Australian Council for Safety and Quality in Health Care. Lessons from the inquiry into obstetrics and gynaecological services at King Edward Memorial Hospital 1990–2000. Attachment to Council’s report: safety through action. Improving patient safety in Australia. Third report to the Australian Health Ministers Conference 19 July 2002. Sydney: ACSQ, 2002.
  • 16
    Community and Health Services Complaints Commissioner of the ACT. A final report of the investigation into adverse patient outcomes of neurosurgical services provided by the Canberra Hospital. Canberra, Australia: ACT Government; 2003.
  • 17
    Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002; 346: 171522.
  • 18
    Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288: 198793.
  • 19
    Rothberg MB, Abraham I, Lindenauer PK, Rose DN. Improving nurse-to-patient staffing ratios as a cost-effective safety intervention. Med Care 2005; 43: 78591.
  • 20
    Eucinosa WE, Bernard DM. Hospital finances and patient safety outcomes. Inquiry 2005; 42: 6072.
  • 21
    Faunce TA, Bolsin SNC. Three Australian whistleblowing sagas: lessons for internal and external regulation. Med J Aust 2004; 181: 447.
  • 22
    Benson H, Barbret LC. Impact on quality and patient safety: the new shortage of healthcare professionals. J Healthc Qual 2002; 24: 457.
  • 23
    Mohr JJ, Batalden PB. Improving safety on the front lines: the role of clinical microsystems. Qual Saf Health Care 2002; 11: 4550.
  • 24
    Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation of the MedTeams project. Health Serv Res 2002; 37: 155381.
  • 25
    Borkowski N. Teams and team building. In: BorkowskiN, ed. Organisational Behaviour in Health Care. Boston: Johns and Bartlett Publishers Inc; 2005; 34358.
  • 26
    Firth-Cozens J. Cultures for improving patient safety through learning; the role of teamwork. Qual Health Care 2001; 10 (Suppl. 2): ii26ii31.
  • 27
    Degeling P, Kennedy J, Hill M. Mediating the cultural boundaries between medicine, nursing and management – the central challenge in hospital reform. Health Serv Manage Res 2001; 14: 3648.
  • 28
    West M, Borril C, Dawsom J. The link between the management of employees and patient mortality in acute hospitals. Int J Hum Resour Manage 2002; 13: 1299310.
  • 29
    Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision-making: a national study of preferences. J Gen Intern Med 2005; 20: 5315.
  • 30
    National Health and Medical Research Council (NHMRC). Making decisions about tests and treatments. Principles for better communication between healthcare consumers and healthcare professionals. Canberra: NHMRC; 2006. Available at: www.nhmrc.gov.au
  • 31
    Rankin SH, Stallings KD, London F. Patient Education in Health and Illness, 5th edn. Baltimore: Lippincott Williams and Wilkins; 2005.
  • 32
    O’Connor AM, Rostom A, Fiset V. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ 1999; 319: 7314.
  • 33
    Holman H, Lorig K. Patients as partners in managing chronic illness. BMJ 2000; 320: 5267.
  • 34
    Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine Roundtable on Health Care Quality. JAMA 1998; 280: 10001005.
  • 35
    Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care. How might more be worse? JAMA 1999; 281: 44653.
  • 36
    Bhatt DL, Roe MT, Peterson ED, Li Y, Chen AY, Harrington RA et al. CRUSADE Investigators. Utilisation of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 2004; 292: 2096104.
  • 37
    Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347: 818.
  • 38
    Lagrew DC Jr, Adashek JA. Lowering the cesarean section rate in a private hospital: comparison of individual physicians’ rates, risk factors, and outcomes. Am J Obstet Gynecol 1998; 178: 120714.
  • 39
    Gotzeche PC. On the benefits and harms of screening for breast cancer. Int J Epidemiol 2004; 33: 5673.
  • 40
    Fleshner N, Rakovitch E, Klotz L. Differences between urologists in the United States and Canada in the approach to prostate cancer. J Urol 2000; 163: 14616.
  • 41
    Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook RH. The appropriateness of carotid endarterectomy. N Engl J Med 1988; 318: 7217.
  • 42
    Wright J. The double-edged sword of COX-2 selective NSAIDs. CMAJ 2002; 167: 11317.
  • 43
    Scott IA, Darwin I, Duke A, Harvey K, Harden H, Ward M et al. Optimising cardiac care in Queensland public hospitals. Results of a multi-site quality improvement collaboration. Med J Aust 2004; 180: 3927.
  • 44
    National Institute of Clinical Studies (NICS). Evidence-Practice Gaps Report, Vol. 1. Melbourne: NICS; 2003.
  • 45
    Duffy BK, Phillips PA, Davis SM, Donnan GA, Vedadhaghi ME. Stroke in hospitals: an Australian review of treatment investigators. Evidence-based care and outcomes of acute stroke managed in hospital specialty units. Med J Aust 2003; 178: 31823.
  • 46
    National Institute of Clinical Studies (NICS. Evidence-Practice Gaps Report, Vol. 2. Melbourne: NICS; 2005.
  • 47
    McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348: 263545.
  • 48
    Campbell D, Scott I, Andersen J, Greenberg P. Improving clinical practice: what works and what does doesn’t? Intern Med J 2001; 31: 53640.
  • 49
    Scott IA, Denaro CP, Bennett CJ, Mudge AM. Towards effective use of decision support in clinical care – what the guidelines for guidelines don’t tell you. Intern Med J 2004; 34: 492500.
  • 50
    Cabana M, Rand C, Powe N, Wu AW, Wilson MH, Abboud PA et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 145865.
  • 51
    Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8: iiiiv, 1–72.
  • 52
    Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330: 76572.
  • 53
    ShojaniaKG, DuncanBW, McDonaldKM, WachterRM, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality; 2001. Evidence Report/Technology Assessment No.: 43, AHRQ Publication No.: 01–E058.
  • 54
    National Quality Forum. Safe Practices for Better Healthcare – A Consensus Report. Washington: National Quality Forum; 2003.
  • 55
    Gaba D. Structural and organisational issues in patient safety: a comparison of health care to other high-hazard industries. Calif Manage Rev 2000; 43: 83102.
  • 56
    Spencer FC. Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg 2000; 191: 41018.
  • 57
    Hoff T, Jameson L, Hannan E, Flink E. A review of the literature examining linkages between organizational factors, medical errors, and patient safety. Med Care Res Rev 2005; 61: 337.
  • 58
    Francois P, Peyrin JC, Touboul M, Labarere J, Reverdy T, Vinck D. Evaluating implementation of quality management systems in a teaching hospital’s clinical departments. Int J Qual Health Care 2003; 15: 4755.
  • 59
    McNamara P. Quality-based payment: six case examples. Int J Qual Health Care 2005; 17: 35762.
  • 60
    Young GJ, White B, Burgess JF, Berlowitz D, Meterko M, Guldin MR et al. Conceptual issues in the design and implementation of pay-for-quality programs. Am J Med Qual 2005; 20: 14450.
  • 61
    Westrum R. A typology of organisational cultures. Qual Saf Health Care 2004; 13 (Suppl. 2): ii22ii27.
  • 62
    Russell EM, Bruce J, Krukowski ZH. Systematic reviews of the quality of surgical mortality monitoring. Br J Surg 2003; 90: 52732.
  • 63
    Black N, Barker M, Payne M. Cross sectional survey of multicentre clinical databases in the United Kingdom. BMJ 2004; 328: 147882.
  • 64
    Runciman WB, Webb RK, Helps SC, Thomas EJ, Sexton EJ, Studdert DM et al. A comparison of iatrogenic injury studies in Australia and the USA. II. Reviewer behaviour and quality of care. Int J Qual Health Care 2000; 12: 37988.
  • 65
    Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet 2004; 363: 10617.
  • 66
    Zhan C, Miller MR. Administrative data based patient safety research: a critical review. Qual Saf Health Care 2003; 12: 5863.
  • 67
    Schiff GD, Klass D, Peterson J, Shah G, Bates DW. Linking laboratory and pharmacy: opportunities for reducing errors and improving care. Arch Intern Med 2003; 163: 893900.
  • 68
    Holman CD, Bass AJ, Rouse IL, Hobbs MS. Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health 1999; 23: 4539.
  • 69
    Hammermeister KE, Shrover AL, Sethi GK, Grover FL. Why it is important to demonstrate linkages between outcomes of care and processes and structures of care. Med Care 1995; 33 (10 Suppl.): OS516.
  • 70
    Mehta R, Montoye C, Gallogly M, Baker P, Blount A, Faul J. GAP Steering Committee of the American College of Cardiology. Improving quality in the care of acute myocardial infarction: the Guidelines Applied to Practice (GAP) Initiative. JAMA 2002; 287: 126976.
  • 71
    LaBresh KA, Ellrodt AG, Gliklich R, Liljestrand J, Peto R. Get with the guidelines for cardiovascular secondary prevention. Pilot results. Arch Intern Med 2004; 164: 2039.
  • 72
    Smith CA, Varkey AB, Evans AT, Reilly BM. Evaluating the performance of inpatient attending physicians. A new instrument for today’s teaching hospitals. J Gen Intern Med 2004; 19: 76671.
  • 73
    Kinley H, Czoski-Murray C, George S, McCabe C, Primrose J, Reilly C et al. Extended scope of nursing practice: a multicentre randomised controlled trial of appropriately trained nurses and pre-registration house officers in pre-operative assessment in elective general surgery. Health Technol Assess 2001; 5: 187.
  • 74
    National Patient Safety Education Framework Project Team. Final Draft of the National Patient Safety Education Framework. Framework Documents. Sydney: University of Sydney, ACSQ, Centre for Innovation in Professional Health Education; 2005 Feb [accessed 2007 Mar 3]. Available from URL: www.patientsafety.org.au/pdfdocs/national_patient_safety_education_framework.pdf
  • 75
    NHS Modernisation Agency. Redesign and extend roles in line with efficient patient pathways to attract and retain an effective workforce. In: 10 High Impact Changes for Service Improvement and Delivery. A Guide for NHS Leaders. London: NHS Modernisation Agency; 2004; 7985.
  • 76
    Australian Council for Quality and Safety in Health Care. Clinical Handover and Patient Safety. Literature Review Report. Sydney: ACSQ; 2005 Mar [accessed 2007 Mar 3]. Available from URL: www.safetyandquality.org
  • 77
    Buist MD, Jarmolowski E, Burton PR, Bernard SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admissions to intensive care. A pilot study in a tertiary care hospital. Med J Aust 1999; 171: 225.
  • 78
    Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe ME. Communication loads on clinical staff in the emergency department. Med J Aust 2002; 176: 41518.
  • 79
    McWilliam CL, Sangster JF. Managing patient discharge to home: the challenges of achieving quality of care. Int J Qual Health Care 1994; 6: 14761.
  • 80
    Davis D, Evans M, Jadad A, Perrier L, Rath D, Ryan D et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003; 327: 335.
  • 81
    Australian Council for Quality and Safety in Health Care. National Medication Safety Breakthrough Collaboration. Improvement Toolkits 1 & 2. Sydney: ACSQ; 2005 [accessed 2007 Mar 3]. Available from URL: www.safetyandquality.org
  • 82
    NSW Therapeutics Advisory Group Inc. Manual of Indicators for Drug Use in Australian Hospitals. Sydney: Darlinghurst; 1998 Apr [accessed 2007 Mar 3]. Available from URL: www.ciap.health.nsw.gov.au/nswtag/publications/otherdocs/draftindicatorsmanual201106.pdf
  • 83
    Jha AK, Li Z, Orav EJ, Epstein AM. Care in US hospitals – the Hospital Quality Alliance Program. N Engl J Med 2005; 353: 26574.
  • 84
    Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in US hospitals as reflected by standardized measures, 2002–2004. N Engl J Med 2005; 353: 25564.
  • 85
    Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program. Med J Aust 2001; 174: 6215.
  • 86
    Carey RG. How do you know that your care is improving? Part 1: basic concepts in statistical thinking. J Ambul Care Manage 2002; 25: 8087.
  • 87
    Carey RG. How do you know that your care is improving? Part 2: using control charts to learn from your data. J Ambul Care Manage 2002; 25: 7888.
  • 88
    Lim TO, Soraya A, Ding LM, Morad Z. Assessing doctors‘ competence: application of CUSUM technique in monitoring doctors’ performance. Int J Qual Health Care 2002; 14: 2518.
  • 89
    Kazel R. Minnesota insurer won’t pay hospitals for “never events.” American Medical News 2004 Nov 8.
  • 90
    Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293: 1197203.
  • 91
    Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11: 10412.
  • 92
    Plsek PE, Greenhalgh T. Complexity science. The challenge of complexity in health care. BMJ 2001; 323: 6258.
  • 93
    Peat JK, Toelle BG, Nagy SA. Qualitative research: a path to better healthcare. Med J Aust 1998; 169: 3279.
  • 94
    Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organisations: systematic review and recommendations. Milbank Q 2004; 82: 581629.
  • 95
    Berwick DM. Disseminating innovations in health care. JAMA 2003; 289: 196975.
  • 96
    Carroll JS, Quijada MA. Redirecting traditional professional values to support safety: changing organisational culture in health care. Qual Saf Health Care 2004; 13 (Suppl. 2): ii16ii21.
  • 97
    Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005; 142: 75664.