Healthcare Quality Improvement and Patient Safety

Topic Leader: Dr. Lukasz Mazur
School of Medicine – University of North Carolina

Topic Leader: Dr. Prithima Moslay
School of Medicine – University of North Carolina

Recommended Books

  • Institute of Medicine (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press.
  • Institute of Medicine (2005). Building a Better Delivery System: A New Engineering/Health Care Partnership, Washington, DC: National Academies Press.
  • Institute of Medicine (2006).  Preventing Medication Errors: Quality Chasm Series, Washington, DC: National Academies Press. 
  • Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Second Edition by Pascal Carayon, Nov 9, 2011.
  • Bongers, M. S. Human Error in Medicine Hillsdale,1994NJ: Lawrence Erlbaum Associates Inc.
  • Casey, S. 1993. Set Phasers On Stun and Other True Tales of Design, Technology, and Human Error. Santa Barbara, CA: Aegean Publishing. 
  • Reason, J.T. 1990. Human Error. Cambridge, England: Cambridge University Press 
  • Whittingham, R. B. 2004. The Blame Machine: Why Human Error Causes Accidents, Elsevier Butterworth-Heinemann publications 
  • Sanders, J. & Cook, G. (2007) ABC of Patient Safety. Oxford: Blackwell.

Recommended Articles

  • Institute of Healthcare Improvement (2005). Going Lean in Health Care, Innovation Series.
  • Berwick, D (2002). A user’s manual for the IOM’s “quality chasm” report. Health Affairs. 21(3), 80-90.
  • Batalden, PB, Davidoff, F (2007).  What is ‘quality improvement’ and how can it transform healthcare, Quality and Safety of Health Care, (16) 2-3.
  • Alexander JA, Weiner BJ, Shortell SM, Baker, LC, Becker MP (2006). The role of organizational infrastructure in implementation of hospitals’ quality improvement. Hospital Topics, 84(1),11-20.
  • Ramanujam, R and Rousseau, DM (2006). The challenges are organizational, not just clinical, Journal of Organizational Behavior, 27, 811-827.
  • Weingart, SN,  Morath, JM, and Ley, C (2003).  Learning with leaders to create safe health care: the executive session on patient safety, Journal of Clinical Outcomes Management, 10, 597–601.
  • Weingart, SN and Page, D (2004). Implications for practice: challenges for healthcare leaders in fostering patient safety, Quality and Safety in Health Care, 13(6).
  • Alexander JA, Weiner BJ, Shortell SM, Baker LC (2007). Does quality improvement implementation affect hospital quality of care? Hospital Topics, 85(2), 3-12.
  • Christensen, CM, Bohmer, R and Kenagy, J (2000). Will disruptive innovations cure health care?, Harvard Business Review, 4(2) 94–111.
  • Tucker, AL and Edmondson, AC (2002). Managing routine exception: a model of nurse problem solving behavior, Advances in Healthcare Management, 3, 87-113.
  • Tucker, AL and Edmondson, AC (2003). Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change, California Management Review, 45(2) 55-72.
  • Tucker, AL, Edmondson, AC, and Spear, S (2002). When problem solving prevents organizational learning, Journal of Organizational Change Management, 15(2), 122-137.
  • Sobek, DK and Jimmerson, C (2003).  Applying the Toyota Production System to a Hospital Pharmacy, Paper Presented at the Industrial Engineering Research Conference, Portland, Oregon.
  • Sobek, DK, and Jimmerson, C (2004).  A3 Reports: Tool for Process Improvement, Paper Presented in the Industrial Engineering Research Conference, Houston, Texas.
  • Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle, 1998. Applying Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of Clinical Monitoring and Computing 14: 253-263.
  • Gosbee, J. 1998. Communication among health professionals: Human factors engineering can help make sense of the chaos. British Medical Journal ;316: 642
  • Reasons, J. 1995. Undesrtanding adverse event: human factors. Qual Health Care 1995; 4(2):80-89
  • Billings, C. E. (1999). The NASA Aviation Safety Reporting System: Lessons Learned from Voluntary Incident Reporting. In Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care. National Patient Safety Foundation, Chicago IL (held at Annenberg Center for Health Sciences, Rancho Mirage CA Nov. 8–10, 1998).
  • Cook, R. I., McDonald, J. S., and Smalhout, R. (1989). Human error in the operating room: Identifying cognitive lock up. Cognitive Systems Engineering Laboratory Technical Report 89- TR-07, Columbus, OH: Department of Industrial and Systems Engineering, The Ohio State University
  • Gaba, D. M., Howard, S. K., and Jump, B. (1994). Production pressure in the work environment: California anesthesiologists’ attitudes and experiences. Anesthesiology 81:488-500
  • Lin, L., Isla, R., Doniz, K., Harkness, H., Vicente, K., Doyle, D. (1998). Applying Human Factors to the design of medical equipment: Patient controlled analgesia. Journal of Clinical Monitoring, 14, 253—263
  • Biaggi, P., Peter, S. & Ulich, E. (2003). Stressors, emotional exhaustion, and aversion to patients in residents and chief residents. Swiss Medical Weekly, 133, 339-346
  • Nguyen NT, Ho HS, Smith WD, Philipps C, Lewis C, De Vera RM, Berguer R. An ergonomic evaluation of surgeons' axial skeletal and upper extremity movements during laparoscopic and open surgery.  Am J Surg. 2001 Dec;182(6):720-4.
  • Wears RL, Perry SJ.  Human factors and ergonomics in the emergency department.  Ann Emerg Med. 2002; 40:206-212.
  • Woods, D. D., Cook, R. I. and Billings, C.E. (1995). The impact of technology on physician cognition and performance. Journal of Clinical Monitoring,, 11:92-95
  • Buckle, P., Clarkson, P., Coleman, R., Ward, J. & Anders, J. (2006) Patient safety, systems design and ergonomics. Applied Ergonomics, 37, 491-500
  • Cox, T., Randall, R. & Griffiths, A. (2002) Interventions to Control Stress at Work in Hospital Staff. Sudbury: HSE Books
  • Helmreich, R. (2000) On error management: lessons from aviation. British Medical Journal, 320, 781-785.
  • Helmreich, R. & Merritt, A. (1998) Culture at Work in Aviation and Medicine. Aldershot: Ashgate.
  • Krueger, G. (1989) Sustained work, fatigue, sleep loss and performance: A review of the issues. Work and Stress, 3, 121-141
  • Moray, N. (2000) Culture, politics and ergonomics. Ergonomics, 43, 868-868.
  • Henriksen K. Macroergonomic interdependence in patient safety research. Paper presented at XVth Triennial Congress of the International Ergonomics Association and the 7th Joint Conference of Ergonomics Society of Korea/Japan Ergonomics Society; August 2003; Seoul, Korea

Recommended IERC Papers

  • Mazur, L.M., Rothenberg, L., McCreery, J. “Measuring and Understanding Change Recipients’ Buy-In during Lean Transformation Program,” IIE Annual Conference and Expo, Reno, May, 2011.
  • Mazur, L.M., McCreery, J., Rothenberg, L. “Exploring the Power of Social Networks and Leadership Styles during Lean Program Implementation in Hospitals,” IIE Annual Conference and Expo, Reno, May, 2011.
  • Hummer, D., Mazur, L.M., Lefteris, C., Grant, H., "Assessment between Organizational Climate and Lean Behaviors,” IIE Annual Conference and Expo, Orlando, May, 2012.
  • Moslay, P., Mazur, L.M., Jackson, M., Chang, S.X., Ph.D, Burkhardt, D.K., Adams, R., Jones, E.L., X., J., Rockwell, J., and Marks, L.B. "Empirical Evaluation of Workload of the Radiation Oncology Physicist during Radiation Treatment Planning and Delivery", Human Factors and Ergonomics Society's 55th Annual Meeting, Las Vegas, 2011.
  • Jackson, M., and Mazur, L.M., “Exploring Lean Transformation using Theory of Planned Behavior,” IIE Annual Conference and Expo, Reno, May, 2011.
  • Mazur, L.M., McCreery, J., Rothenberg, L. “Research and Evaluation of Engineering Management Approaches for Continuous Improvement in Rural Hospitals,” IIE Annual Conference and Expo, Cancun, Mexico, June 2010. Selected as one of the 5 best papers in Engineering Management Track.  
  • Poole, T., Mazur, L.M. “Assessing Readiness for Lean Change in Emergency Department,” IIE Annual Conference and Expo, Cancun, Mexico, June 2010.
  • Mosley, P., Jackson, M., Taylor, K., Xu, J., and Mazur, L.M. “Assessment of Mental and Physical Workload of Nursing Staff in High Dosage Radiation Treatment Room,” IIE Annual Conference and Expo, Cancun, Mexico, June 2010.
  • Gebicki, M., Andrikopoulos, A., Hume, M., Mazur, L.M., and Chen, S-J. “Methods and Skills for Effective Health Care Processes Improvement: A Lean Engineering Approach” IIE Annual Conference and Expo, Miami, Florida, May 2009.