Recommended Reading List

Recommended reading for residents and students interested in quality and safety. This list includes 30-plus curated articles that provide a well-rounded introduction to the field, including root cause analysis, systems analysis, patient safety, culture, and change management.

Patient Safety and Systems Thinking

  • AHRQ PSNet Patient Safety Primers: “Systems Approach” and “Root Cause Analysis”.
  • “Error in Medicine.”  Leape LL.  JAMA 1994; 272: 1851-7.
  • “The Wrong Patient.” Chassin MR, Becher EC. Ann Intern Med 2002; 136:826-833.
  • “Understanding medical error and improving patient safety in the inpatient setting.”  Shojania KG et al, Med Clin N Am 86 (2002) 847–867.

Measurement of Patient Safety and Healthcare Quality

  • AHRQ PSNet Patient Safety Primers: “Detection of Safety Hazards”“Never Events” and “Voluntary Event Reporting”.
  • “The Quality of Care:  How can it be assessed?”  Donabedian A.  JAMA 1988.
  • The Bell Curve”.  Gawande A.  The New Yorker, November 29, 2004.
  • “The Elephant of Patient Safety: What you See Depends on How You Look.” Shojania KJ, Joint Commission Journal on Quality and Patient Safety (2010); 36(9): 399-401.
  • “Accidental Deaths, Saved Lives, and Improved Quality.”  Brennan T et al, New England Journal of Medicine, 2005; 353(13): 1405-1409.

Approaches to Improving Healthcare Quality and Safety

  • AHRQ PSNet Patient Safety Primers: “Human Factors Engineering”“Checklists”, and “Root Cause Analysis”.
  • “How do good ideas spread?” Gawande A. The New Yorker, July 29, 2013.
  • “The Checklist.”  Gawande A.  The New Yorker, December 10, 2007.
  • “Reality check for checklists.” Bosk CL et al, Lancet, Volume 374, Issue 9688, Pages 444 – 445, 8 August 2009.
  • “The tension between needing to improve care and knowing how to do it.”  Auerbach AD, Landefeld CS, Shojania KG.  N Engl J Med 2007; 357(6): 608-13.
  • “The science of improvement.”  Berwick DM.  JAMA 2008; 299(10): 1182-4.
  • “Explaining Michigan: developing an ex post theory of a quality improvement program.” Dixon-Woods M et al, The Milbank Quarterly, Vol. 89, No. 2, 2011 (pp. 167–205).
  • “Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature.” Dixon-Woods M et al, BMJ Qual Saf 2012;21:876–884.
  • “Harnessing the power of feedback loops.” Goetz T, Wired magazine, June 2011.
  • If Health Care is Going to Change, Dr. Brent James’ Ideas Will Change It.”  The New York Times Magazine, November 8, 2009.
  • “The Promise of Lean in Health Care.” Toussaint JS, Berry L. Mayo Clinic Proceedings 2013;88(1):74-82.
  • “Redesigning health care with insights from the science of complex adaptive systems.”  Plsek P et al, Appendix B in Crossing the Quality Chasm: A New Health Care System for the 21st Century. Institute of Medicine, 2001.

Leadership and Change Management

  • “What makes a leader?” Goleman D, The Best of Harvard Business Review, 1998.
  • “The discipline of teams.”  Katzenbach JR and Smith DK, The Best of Harvard Business Review, 1993.
  • “Strategies for learning from failure.”  Edmondson A. Harvard Business Review, 2011.
  • “A Business School View of Medical Interprofessional Rounds: Transforming Rounding Groups Into Rounding Teams.” Bharwani AM et al, Acad Med. 2012;87:1768–1771.

Safety Culture

  • AHRQ PSNet Patient Safety Primers: “Safety Culture”, and “The Role of the Patient in Safety”.
  • “Balancing ‘no blame’ with accountability in patient safety.” Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
  • “Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal Infirmary.”  Weick K.  California Management Review 2003; 45(2) 73-84.
  • “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist.”  Berwick D. Health Affairs, 28(4): w555-w565, 2009.

Healthcare Quality and Value

  • The Cost Conundrum.”  Gawande A.  The New Yorker, June 1, 2009.
  • “Eliminating Waste in US Health Care.” Berwick D, Hackbarth A. JAMA 2012; 307(14):1513-1516.
  • “The physician’s role in controlling medical care costs and reducing waste.” Brooks RH. JAMA. 2011;306(6):650-651.
(Adapted from UCSF and Tulane Patient Safety and Quality Improvement Guide)