Gregory’s Pediatric Anesthesia
Chapter 45 - References
1. American Society of Anesthesiologists. Career Webpage. www.asahq.org/career/challenge.htm
2. Salas E. Teamwork and team training. In: Smelser NJ, Baltes PB (eds) International Encyclopedia
of the Social and Behavioral Sciences. New York: Pergamon, 2001, pp. 15487–92.
3. Kohn LT CJ, Donaldson MS (eds). To Err is Human: Building a Safer Health System. Washington,
Dc: National Academy Press, 2000.
4. Beaty D. The Naked Pilot: The Human Factor in Aircraft Accidents. Marlborough, Wiltshire: Airlife,
1995.
5. Flin R, O'Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-Technical Skills.
Burlington, VA: Ashgate, 2008.
6. Fletcher GC, McGeorge P, Flin RH et al. The role of non-technical skills in anaesthesia: a review
of current literature. Br J Anaesth 2002; 88: 418–29.
7. Gaba DM Howard SK, Fish KJ et al. Simulation-based training in anesthesia crisis resource
management (ACRM): a decade of experience. Simul Gaming 2001; 32: 175–93.
8. Henson LC, Lee AH. Participant evaluation of team oriented medical simulation. In: Simulators in
Anesthesiology Education. New York: Plenum, 1998.
9. Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J
Med Qual 2007; 22: 214–17.
10. Simon R, Langford V, Locke A et al. (2000) A successful transfer of lessons learned in aviation
psychology and flight safety to health care: the MedTeams system. Patient Safety Initiative 2000.
Chicago: National Patient Safety Foundation.
11. Gaba DM. What does simulation add to teamwork training?
www.webmm.ahrq.gov/perspective.aspx?perspectiveID=20
.
12. Pratt SD, Sachs B. Team training: classroom training vs. high–fidelity simulation.
www.webmm.ahrq.gov/perspective.aspx?perspectiveID=21.
13. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course.
www.ahrq.gov/teamsteppstools/instructor/fundamentals/index.html.
14. Clancy CM. TeamSTEPPS: optimizing teamwork in the perioperative setting. AORN J 2007; 86:
18–22.
15. McIntyre RM, Salas E. Measuring and managing for team performance: emerging principles
from complex environments. In: Guzzo R, Salas E (eds) Team Effectiveness and Decision Making in
Organizations. San Francisco: Jossey-Bass, 1995, pp. 9–45.
16. McFerran S, Nunes J, Pucci D et al. Perinatal Patient Safety Project: a multicenter approach to
improve performance reliability at Kaiser Permanente. J Perinat Neonatal Nurs 2005; 19: 37–45.
17. Joint Commission on Accreditation of Healthcare Organizations. Sentinel events glossary of
terms. www.jointcommission.org/sentinelevents/se_glossary.htm .
18. Joint Commission on Accreditation of Healthcare Organizations. Improving handoff
communication: meeting national patient safety goal 2E. Joint Perspect Patient Saf 2006; 6: 9–15.
19. Joint Commission on Accreditation of Healthcare Organizations. Improving America's Hospitals.
The Joint Commission's Annual Report on Quality and Safety. Washington, DC: Joint Commission
on Accreditation of Healthcare Organizations, 2007.
20. Greenberg CC, Regenbogen SE, Studdert DM et al. Patterns of communication breakdowns
resulting in injury to surgical patients. J Am Coll Surg 2007; 204: 533–40.
21. Streitenberger K, Breen-Reid K, Harris C. Handoffs in care – can we make them safer? Pediatr
Clin North Am 2006; 53: 1185–95.
22. Catchpole KR, de Leval MR, McEwan A et al. Patient handover from surgery to intensive care:
using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007;
17: 470–8.
23. Wayne JD, Tyagi R, Reinhardt G et al. Simple standardized patient handoff system that
increases accuracy and completeness. J Surg Educ 2008; 65: 476–85.
24. Salerno SM, Arnett MV, Domanski JP. Standardized sign-out reduces intern perception of
medical errors on the general internal medicine ward. Teach Learn Med 2009; 21: 121–6.
25. Ferran NA, Metcalfe AJ, O'Doherty D. Standardised proformas improve patient handover: audit
of trauma handover practice. Patient Saf Surg 2008; 2: 24.
26. Borowitz SM, Waggoner-Fountain LA, Bass EJ et al. Adequacy of information transferred at
resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care 2008;
17: 6–10.
27. Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive
care unit: using a scoring tool to direct quality improvements in handover. Crit Care Med 2009; 37:
2905–12.
28. Bhabra G, Mackeith S, Monteiro P et al. An experimental comparison of handover methods. Ann
R Coll Surg Engl 2007; 89: 298–300.
29. Chang VY, Arora VM, Lev-Ari S et al. Interns overestimate the effectiveness of their hand-off
communication. Pediatrics 2010; 125: 491–6.
30. Horwitz LI, Moin T, Krumholz HM et al. What are covering doctors told about their patients?
Analysis of sign-out among internal medicine house staff. Qual Saf Health Care 2009; 18: 248–55.
31. Rogers SO Jr, Gawande AA, Kwaan M et al. Analysis of surgical errors in closed malpractice
claims at 4 liability insurers. Surgery 2006; 140: 25–33.
32. Horwitz LI, Moin T, Krumholz HM et al. Consequences of inadequate sign-out for patient care.
Arch Intern Med 2008; 168: 1755–60.
33. Singh H, Thomas EJ, Petersen LA et al. Medical errors involving trainees: a study of closed
malpractice claims from 5 insurers. Arch Intern Med 2007; 167: 2030–6.
34. Solet DJ, Norvell JM, Rutan GH et al. Lost in translation: challenges and opportunities in
physician-to-physician communication during patient handoffs. Acad Med 2005; 80: 1094–9.
35. Riesenberg LA, Leitzsch J, Massucci JL et al. Residents' and attending physicians' handoffs: a
systematic review of the literature. Acad Med 2009; 84: 1775–87.
36. Riesenberg LA, Leisch J, Cunningham JM. Nursing handoffs: a systematic review of the
literature. Am J Nurs 2010; 110: 24–34; quiz 5–6.
37. Sabir N, Yentis SM, Holdcroft A. A national survey of obstetric anaesthetic handovers.
Anaesthesia 2006; 61: 376–80.
38. Horn J, Bell MD, Moss E. Handover of responsibility for the anaesthetised patient – opinion and
practice. Anaesthesia 2004; 59: 658–63.
39. Cleland JA, Ross S, Miller SC et al. "There is a chain of Chinese whispers ...": empirical data
support the call to formally teach handover to prequalification doctors. Qual Saf Health Care 2009;
18: 267–71.
40. Chu ES, Reid M, Schulz T et al. A structured handoff program for interns. Acad Med 2009; 84:
347–52.
41. Henkind SJ, Sinnett JC. Patient care, square-rigger sailing, and safety. JAMA 2008; 300: 1691–
3.
42. Dracup K, Morris PE. Passing the torch: the challenge of handoffs. Am J Crit Care 2008; 17: 95–
7.
43. Vidyarthi AR, Arora V, Schnipper JL et al. Managing discontinuity in academic medical centers:
strategies for a safe and effective resident sign-out. J Hosp Med 2006; 1: 257–66.
44. Patterson ES, Roth EM, Woods DD et al. Handoff strategies in settings with high consequences
for failure: lessons for health care operations. Int J Qual Health Care 2004; 16: 125–32.
45. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J
Med Qual 2009; 24: 196–204.
46. Cooper JB, Newbower RS, Long CD et al. Preventable anesthesia mishaps: a study of human
factors. Anesthesiology 1978; 49: 399–406.
47. Gawande A. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books,
2009.
48. O'Grady NP, Alexander M, Dellinger EP et al. Guidelines for the prevention of intravascular
catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;
51: 1–29.
49. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725–32.
50. Frankel HL, Crede WB, Topal JE et al. Use of corporate Six Sigma performance-improvement
strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll
Surg 2005; 201: 349–58.
51. Marra AR, Cal RG, Durao MS et al. Impact of a program to prevent central line-associated
bloodstream infection in the zero tolerance era. Am J Infect Control 2010; 38(6): 434–9.
52. Schelonka RL, Scruggs S, Nichols K et al. Sustained reductions in neonatal nosocomial infection
rates following a comprehensive infection control intervention. J Perinatol 2006; 26: 176–9.
53. Wirtschafter DD, Pettit J, Kurtin P et al. A statewide quality improvement collaborative to reduce
neonatal central line-associated blood stream infections. J Perinatol 2010; 30: 170–81.
54. Miller MR, Griswold M, Harris JM 2nd et al. Decreasing PICU catheter-associated bloodstream
infections: NACHRI's quality transformation efforts. Pediatrics 2010; 125: 206–13.
55. Pronovost P, Berenholtz S, Dorman T et al. Improving communication in the ICU using daily
goals. J Crit Care 2003; 18: 71–5.
56. Halm MA. Daily goals worksheets and other checklists: are our critical care units safer? Am J
Crit Care 2008; 17: 577–80.
57. Narasimhan M, Eisen LA, Mahoney CD et al. Improving nurse–physician communication and
satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Care 2006; 15: 217–22.
58. Dobkin E. Checkoffs play key role in SICU improvement. Healthcare Benchmarks Qual Improv
2003; 10: 113–15.
59. Weiser TG, Regenbogen SE, Thompson KD et al. An estimation of the global volume of surgery:
a modelling strategy based on available data. Lancet 2008; 372: 139–44.
60. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and
mortality in a global population. N Engl J Med 2009; 360: 491–9.
61. De Vries EN, Prins HA, Crolla RM et al. Effect of a comprehensive surgical safety system on
patient outcomes. N Engl J Med 2010; 363: 1928–37.
62. Bosk CL, Dixon-Woods M, Goeschel CA et al. Reality check for checklists. Lancet 2009; 374:
444–5.
63. Stelfox HT, Palmisani S, Scurlock C et al. The "To Err is Human" report and the patient safety
literature. Qual Saf Health Care 2006; 15: 174–8.
64. Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687
practitioners. Can J Anaesth 2001; 48: 139–46.
65. Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law. N Z Med J 1995;
108: 185–7.
66. Webster CS, Larsson L, Frampton CM et al. Clinical assessment of a new anaesthetic drug
administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia
2010; 65: 490–9.
67. Webster CS, Merry AF, Larsson L et al. The frequency and nature of drug administration error
during anaesthesia. Anaesth Intensive Care 2001; 29: 494–500.
68. Llewellyn RL, Gordon PC, Wheatcroft D et al. Drug administration errors: a prospective survey
from three South African teaching hospitals. Anaesth Intensive Care 2009; 37: 93–8.
69. Sandnes DL SL, Posner KL, Domino KB. Liability associated with medication errors in
anesthesia: closed claims analysis. Anesthesiology 2008; 109: A770.
70. Eichhorn J. APSF Hosts Medication Safety Conference. Anesthesia Patient Safety Foundation
Newsletter 25, 1–10. www.apsf.org/newsletters/html/2010/spring/01_conference.htm.
71. Christianson JB, Knutson DJ, Mazze RS. Physician pay-for-performance. Implementation and
research issues. J Gen Intern Med 2006; 21 (Suppl 2): S9–S13.
72. Pay-for-Performance and Anesthesiology Quality Incentive Measures (August 18, 2006).
http://asatest.asahq.org/Washington/P4P.htm
73. Centers for Medicare & Medicaid Services. 2010 PQRI Measures List. www.cms.gov/PQRI/.
74. Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med
Care Res Rev 2006; 63: 135–57.
75. Lindenauer PK, Remus D, Roman S et al. Public reporting and pay for performance in hospital
quality improvement. N Engl J Med 2007; 356: 486–96.
76. Rosenthal MB, Frank RG, Li Z et al. Early experience with pay-for-performance: from concept to
practice. JAMA 2005; 294: 1788–93.
77. Town R, Kane R, Johnson P et al. Economic incentives and physicians' delivery of preventive
care: a systematic review. Am J Prev Med 2005; 28: 234–40.
78. Cunningham R. Stimulus bill implementation: expanding meaningful use of health IT. NHPF
Issue Brief 2009; 1–16.
79. Thomasian J. Preparing to Implement HITECH: A State Guide for Electronic Health Information
Exchange.
Washington,
DC:
NGA
Center
for
Best
Practices,
2009,
p.
1–31.
www.nga.org/Files/pdf/0908ehealthhitech.pdf
80. Ehrenfeld JM, Rehman MA. Anesthesia information management systems: a review of
functionality and installation considerations. J Clin Monit Comput 2010; 25(1): 71–9.
81. Landrigan CP, Parry GJ, Bones CB et al. Temporal trends in rates of patient harm resulting from
medical care. N Engl J Med 2010; 363: 2124–34.
82.
World
Health
Organization.
World
Health
Organization
Surgical
Safety
Checklist.
www.who.int/patientsafety/safesurgery/en/index.html.
83. Rall M, Gaba DM. Human performance and patient safety. In Miller RD (ed) Miller’s Anesthesia,
7th edn. Philadelphia: Elsevier Churchill Livingstone, 2010, p. 107.