Recommended Reading

Advances in Patient Safety: From Research to Implementation
A four-volume set of 140 peer-reviewed articles that represents an overview of patient safety studies by AHRQ-funded research and other government-sponsored research, including Military Health System patient safety improvement initiatives.

Building a Better Delivery System: A New Engineering/Health Care Partnership
The report provides a framework for change and an action plan for a systems approach to health care delivery based on a partnership between engineers, health care professionals, and health care managers. The report describes opportunities and challenges to using systems engineering, information technologies, and other tools to advance a twenty-first century system capable of delivering safe, effective, timely, patient-centered, efficient, equitable health care—a system that embodies the six “quality aims” envisioned in Crossing the Quality Chasm. (National Academies, July 2005)

Crossing the Quality Chasm: A New Health System for the 21st Century
This report calls for fundamental change to close the quality gap, recommends a redesign of the American health care system, and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. It offers a set of performance expectations for the 21st century health care system, a set of 10 new rules to guide patient-clinician relationships, a suggested organizing framework to better align incentives inherent in payment and accountability with improvement in quality, and key steps to promote evidence-based practice and strengthen clinical information systems. (Institute of Medicine, March 2001)

Five Years After To Err Is Human
Five years ago, the Institute of Medicine called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to a focus on changing systems. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. (Journal of the American Medical Association, May 18, 2005)

Health Information Technology Leadership Panel: Final Report
The report contains the findings of nine CEOs from leading U.S. companies who purchase a substantial amount of health care for their employees. Investment in information technology is cited as an essential, high priority for the American health care system and the U.S. economy. (The Lewin Group, May 11, 2005)

Leapfrog Hospital Quality and Safety Survey Results
The results of the survey wide variation in the rate of adoption of the recommended practices. For example, while 80% of hospitals have procedures to avoid wrong-site surgery, only 40% have protocols to prevent malnutrition in patients.

Quality Through Collaboration: The Future of Rural Health
It examines the quality of healthcare in rural America. Information technology was among the items the Institute of Medicine listed as a means to address the quality challenges in rural healthcare. The IOM recommended investing in an information and communications technology infrastructure to enhance health and healthcare over the coming decade. (Institute of Medicine, November 2004)

Revolutionizing Health Care Through Information Technology
The recommendations are a framework for a 21st century health care information infrastructure that revolutionizes medical records systems. The four core elements of this framework are: electronic health records for all Americans, computer-assisted clinical decision support, computerized provider order entry and secure, private, interoperable, electronic health information exchange. (President’s Information Technology Advisory Committee, June 2004)

To Err is Human: Building a Safer Health System
The combined goal of the recommendations is for the external environment to create sufficient pressure to make errors costly to health care organizations and providers, so they are compelled to take action to improve safety. At the same time, there is a need to enhance knowledge and tools to improve safety and break down legal and cultural barriers that impede safety improvement. (Institute of Medicine, 2000)