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1 The Hidden Epidemic: The Harvard Medical Practice Study |
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3 | (14) |
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16 | (1) |
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2 It's Not Bad People: Error In Medicine |
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17 | (14) |
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18 | (3) |
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Application of Systems Thinking to Healthcare |
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21 | (8) |
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22 | (3) |
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Response to Error in Medicine |
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25 | (4) |
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29 | (2) |
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3 Changing The System: The Adverse Drug Events Study |
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31 | (14) |
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BWH Center for Patient Safety Research and Practice |
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42 | (2) |
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44 | (1) |
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4 Coming Together: The Annenberg Conference |
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45 | (8) |
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51 | (2) |
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5 A Home Of Our Own: The National Patient Safety Foundation |
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53 | (16) |
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65 | (4) |
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Part II Institutional Responses |
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6 We Can Do This: The Institute For Healthcare Improvement Adverse Drug Events Collaborative |
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69 | (20) |
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72 | (1) |
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73 | (1) |
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The Reducing Adverse Drug Events Collaborative |
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74 | (3) |
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77 | (1) |
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78 | (1) |
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79 | (3) |
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Subsequent IHI Initiatives |
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82 | (3) |
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85 | (1) |
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85 | (4) |
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7 Who Will Lead? The Executive Session |
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89 | (16) |
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First Meeting, January 22--24, 1998 |
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91 | (2) |
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Second Meeting: June 25--27, 1998 |
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93 | (2) |
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Third Meeting: January 21--23, 1999 |
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95 | (1) |
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Fourth Meeting: June 17--19, 1999 |
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96 | (2) |
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Fifth Meeting: January 27--29, 2000 |
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98 | (1) |
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98 | (2) |
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100 | (2) |
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Appendix: 7.1 Executive Session Members |
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102 | (2) |
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CEOs of Healthcare Delivery Organizations |
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102 | (1) |
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Leaders of Health-Related Organizations |
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102 | (1) |
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103 | (1) |
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104 | (1) |
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8 A Community Of Concern: The Massachusetts Coalition For The Prevention Of Medical Errors |
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105 | (22) |
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Medication Consensus Group |
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109 | (1) |
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110 | (1) |
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Regulatory Consensus Group |
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110 | (1) |
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Restraint Consensus Group |
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111 | (2) |
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113 | (1) |
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114 | (1) |
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Implementing Best Practices |
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115 | (1) |
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The Reconciling Medications Project |
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115 | (1) |
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Communicating Critical Test Results |
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116 | (4) |
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120 | (1) |
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Appendix 8.1 Initial Coalition Member Organizations |
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121 | (1) |
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Appendix 8.2 Communicating Critical Test Results |
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122 | (2) |
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124 | (3) |
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9 When The Iom Speaks: Iom Quality Of Care Committee And Report |
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127 | (16) |
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133 | (4) |
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137 | (2) |
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Appendix 9.1 Committee On Quality Of Health Care In America |
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139 | (1) |
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140 | (3) |
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10 The Government Responds: The Agency For Healthcare Research And Quality |
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143 | (16) |
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Response to the IOM Report |
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146 | (3) |
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149 | (6) |
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155 | (2) |
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157 | (2) |
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11 Setting Standards: The National Quality Forum |
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159 | (26) |
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Serious Reportable Events |
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164 | (4) |
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Safe Practices for Better Healthcare |
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168 | (2) |
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170 | (4) |
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171 | (3) |
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Conflict of Interest Scandal |
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174 | (1) |
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175 | (1) |
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Appendix 11.1 Serious Reportable Events Steering Committee |
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176 | (1) |
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Appendix 11.2 NQF Serious Reportable Events |
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177 | (4) |
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Appendix 11.3 NQF Safe Practices |
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181 | (2) |
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183 | (2) |
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12 Enforcing Standards: The Joint Commission |
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185 | (18) |
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History of the Joint Commission |
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185 | (3) |
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188 | (2) |
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190 | (1) |
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Focus on Patient Safety: Sentinel Events |
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191 | (3) |
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194 | (1) |
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195 | (2) |
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197 | (2) |
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199 | (1) |
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Accreditation Process Improvement |
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199 | (1) |
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200 | (1) |
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201 | (2) |
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13 Partners In Progress: Patient Safety In The Uk |
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203 | (12) |
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204 | (1) |
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The Patient Safety Movement |
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205 | (2) |
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The National Patient Safety Agency (NPSA) |
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207 | (1) |
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Additional Safety Efforts |
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208 | (2) |
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Patient Safety in Scotland |
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210 | (1) |
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210 | (1) |
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211 | (1) |
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212 | (3) |
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14 Going Global: The World Health Organization |
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215 | (16) |
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The World Alliance for Patient Safety |
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216 | (1) |
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Guidelines for Adverse Event Reporting and Learning Systems |
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217 | (2) |
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Patient and Consumer Involvement---Patients for Patient Safety (P4PS) |
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219 | (2) |
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Support of Patient Safety Research |
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221 | (2) |
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The Global Patient Safety Challenge |
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223 | (2) |
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225 | (1) |
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226 | (1) |
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Appendix 14.1 The London Declaration |
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227 | (1) |
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227 | (4) |
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15 Just Do It: The Surgical Checklist |
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231 | (12) |
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238 | (1) |
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239 | (4) |
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16 Spreading The Word: The Salzburg Seminar |
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243 | (10) |
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Appendix 16.1 History of the Salzburg Global Seminars |
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247 | (1) |
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Appendix 16.2 Participants in Salzburg Seminar 386 Patient Safety and Medical Error |
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248 | (2) |
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250 | (3) |
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17 Publish Or Perish: British Medical Journal Theme Issue, New England Journal Of Medicine Series |
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253 | (14) |
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NEJM Series on Patient Safety |
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255 | (3) |
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Reporting of Adverse Events |
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258 | (2) |
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Patient Safety and Quality Journals |
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260 | (1) |
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Joint Commission Journal on Quality Improvement and Safety |
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261 | (1) |
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BMJ's Quality and Safety in Health Care |
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261 | (1) |
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The Journal of Patient Safety |
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262 | (1) |
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262 | (1) |
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263 | (4) |
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Part III Getting to Work: Key Issues and How They were Dealt with |
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18 Sleepy Doctors: Work Hours And The Accreditation Council For Graduate Medical Education |
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267 | (26) |
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268 | (1) |
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Early History---What Happened After Zion |
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269 | (2) |
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271 | (1) |
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272 | (3) |
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What Happened: 2003--2008 |
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275 | (1) |
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276 | (1) |
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ACGME Duty Hour Task Force |
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277 | (1) |
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Harvard Conference on Duty Hours |
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278 | (2) |
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280 | (2) |
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282 | (1) |
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283 | (3) |
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286 | (1) |
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287 | (1) |
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288 | (5) |
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19 A Conspiracy Of Silence: Disclosure, Apology, And Restitution |
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293 | (26) |
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296 | (2) |
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298 | (2) |
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300 | (3) |
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When Things Go Wrong---The Disclosure Project |
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303 | (3) |
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306 | (4) |
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The Patient and Family Experience |
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306 | (1) |
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306 | (1) |
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307 | (1) |
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308 | (2) |
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National Progress in Communication and Resolution |
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310 | (4) |
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314 | (1) |
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315 | (4) |
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20 Who Can I Trust? Ensuring Physician Competence |
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319 | (36) |
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320 | (1) |
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321 | (1) |
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322 | (1) |
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Who Is Responsible for Ensuring Physician Competence and Safety? |
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323 | (1) |
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American Board of Medical Specialties |
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324 | (3) |
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Accreditation Council for Graduate Medical Education |
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327 | (1) |
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328 | (1) |
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328 | (2) |
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Federation of State Medical Boards |
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330 | (2) |
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New York Cardiac Advisory Committee |
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332 | (1) |
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The Civil Justice System---Malpractice Litigation |
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333 | (2) |
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Hospital Responsibility for Physician Performance |
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335 | (1) |
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336 | (1) |
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Support of Physicians with Problems |
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337 | (1) |
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How Should it Work? The Ideal System |
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338 | (1) |
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Nonregulatory Approaches to Improving Competence |
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339 | (1) |
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National Surgical Quality Improvement Program |
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339 | (3) |
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Analysis of Patient Complaints |
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342 | (2) |
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National Alliance for Physician Competence |
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344 | (4) |
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The Coalition for Physician Accountability |
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348 | (1) |
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349 | (1) |
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350 | (5) |
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21 Everyone Counts: Building A Culture Of Respect |
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355 | (16) |
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356 | (2) |
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358 | (2) |
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360 | (1) |
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361 | (3) |
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A Culture of Respect, Part 1 The Nature and Causes of Disrespectful Behavior by Physicians |
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362 | (1) |
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A Culture of Respect, Part 2 Creating a Culture of Respect |
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363 | (1) |
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364 | (1) |
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365 | (1) |
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366 | (5) |
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Part IV Creating a Culture of Safety |
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22 Make No Little Plans: The Lucian Leape Institute |
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371 | (30) |
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374 | (3) |
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Teaching Physicians to Provide Safe Patient Care |
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374 | (3) |
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377 | (4) |
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Accelerating Care Integration |
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377 | (4) |
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Through the Eyes of the Workforce |
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381 | (4) |
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Creating Joy, Meaning, and Safer Health Care |
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381 | (4) |
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385 | (3) |
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Partnering with Patients and Families for the Safest Care |
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385 | (3) |
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388 | (5) |
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Safer Health Care Through Transparency |
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388 | (5) |
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393 | (3) |
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396 | (3) |
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396 | (1) |
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Financial Costs of Patient Safety |
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397 | (1) |
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Collaboration with American College of Healthcare Executives |
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398 | (1) |
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399 | (1) |
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399 | (2) |
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23 Now The Hard Part: Creating A Culture Of Safety |
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401 | (1) |
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402 | (3) |
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405 | (1) |
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Characteristics of a Safe Culture |
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406 | (1) |
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407 | (1) |
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High-Reliability Organizations |
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408 | (1) |
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409 | (1) |
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Why Changing Culture Is so Hard to Do |
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410 | (3) |
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413 | (4) |
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417 | (1) |
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Virginia Mason Medical Center |
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417 | (6) |
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423 | (1) |
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Cincinnati Children's Hospital |
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424 | (5) |
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429 | (1) |
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Safe and Reliable Health Care |
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430 | (2) |
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432 | (1) |
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433 | (2) |
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435 | (1) |
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436 | (2) |
Correction to: Everyone Counts: Building a Culture of Respect |
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1 | (438) |
Index |
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439 | |