Front cover -- Patient Safety and Health Care Management -- Copyright page -- Contents -- List of contributors -- List of Reviewers -- Preface: Some observations on patient safety -- Patient safety: State-of-the-art in health care management and future directions -- Assessing the state-of-the-art in patient safety research -- Concluding comments: The future of patient safety -- References -- Part I: Theoretical Perspectives on Managing Patient Safety -- Chapter 1. Evidence-based medicine and patient safety: Limitations and implications -- Defining evidence-based medicine and patient safety -- Contributions of evidence-based medicine to patient safety -- Criticisms of evidence-based medicine and its limitations for patient safety -- Heterogeneity of treatment effects, uncertainty, and quality improvement -- Implications for maximizing patient safety -- Summary and conclusions -- References -- Chapter 2. The anatomy and physiology of error in adverse health care events -- Introduction -- Physiology of error -- Anatomy of error -- Health care error proliferation model -- The role of health care leadership in patient safety -- Conclusion -- Acknowledgments -- References -- Chapter 3. Promoting patient safety by monitoring errors: A view from the middle -- Introduction -- Methods -- Results -- Discussion -- Study limitations -- Conclusion -- References -- Part II: Top Mana Gement Perspectives on Patient Safety -- Chapter 4. Quality and patient safety from the top: A case study of St. Francis medical center governing board's call to action -- A culture of quality and patient safety -- Leadership responsibility for culture change -- Institute for healthcare improvement -- Barriers to effective board quality oversight -- Balanced scoreboard approach -- St. Francis medical center: A case study -- Board quality and patient safety literacy.

Quality and patient safety committee -- Clinical unit/department rounds -- Medical staff credentialing and re-appointment -- Conclusion -- Acknowledgment -- References -- Chapter 5. The trustee and patient safety: Redefining boundaries -- Patient safety concerns intensify -- Historical context -- Hospitals as bureaucracies -- The problem of clinical autonomy of physicians -- Involvement of physicians on boards of trustees -- Conclusion: Patient safety as an increased role for the board -- References -- Chapter 6. Protecting the patient: Collaborating to achieve the ideal hospital work environment -- The effects of a negative work environment -- The intervention -- Project outcomes -- Conclusion -- Acknowledgments -- References -- Part III: Health Information Technology Perspectives on Patient Safety -- Chapter 7. Privacy, security and the national health information network: A mixed methods case study of state-level stakeholder awareness -- The research study -- Case study 1 -- Case study 1 themes -- Case study 2 -- Case study 2 themes -- Cross-case analysis themes -- Discussion -- Note -- References -- Chapter 8. Examining barriers to health information technology adoption -- PDAs: A patient safety tool -- PDAs: Potential impact on the organization -- Methods -- Results -- Discussion -- Implications for health care management -- Acknowledgment -- References -- Part IV: Organizational Behavior and Change Perspectives on Patient Safety -- Chapter 9. Improving patient safety through organizational development: Considering the opportunities -- Background -- Conceptual framework -- Methods -- Results -- A conceptual model -- Discussion -- Conclusion -- Acknowledgments -- References -- Chapter 10. S*t*a*r*t: a great handoff - an approach to effective medical communication in a high-risk environment -- Introduction -- Methods -- Results -- Discussion.

Conclusions -- Acknowledgments -- References -- Chapter 11. Changing a pediatric sub-acute facility to increase safety and reliability -- The guiding lens -- The setting -- The change -- Building an HRO -- The outcomes -- Concluding statements and implications -- References.