Kim Woods

Discussion: Control Mechanisms in Health Services Organizations

Control mechanisms facilitate pathways that health care administrators might consider when deciding how to direct, adjust, and mobilize resources as they apply to day-to-day and business operations. Additionally, control mechanisms assist health care administrators in determining areas where opportunities for improvement might exist in order to facilitate enhanced business and health care delivery practices. As a current or future health care administrator, understanding how to interpret and modify control mechanisms is an essential skill that will contribute greatly to your decision making for enhancing process improvement.

Don't use plagiarized sources. Get Your Custom Essay on

Kim Woods

Just from $13/Page

Order Essay

For this Discussion consider the findings in the Singer article (attached). Then, select a control mechanism that is most appropriate for your HSO or an HSO with which you are familiar. Consider how this control mechanism might apply to promoting a culture of safety as a process improvement initiative in the HSO you selected.

Discussion

Post a description of the control mechanism you selected, and explain its relevance to your HSO. Then, explain how you as a current or future health care administrator might apply this control mechanism to promoting a culture of safety in your HSO; explain why you would apply the mechanism in this way.

500 words minimum

PU34CH22-Singer ARI 13 February 2013 23:6

Reducing Hospital Errors:
Interventions that Build Safety
Culture
Sara J. Singer1 and Timothy J. Vogus2
1 Department of Health Policy and Management, Harvard School of Public Health, Boston,
Massachusetts 02115; email: ssinger@hsph.harvard.edu
2 Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee
37203; email: timothy.vogus@owen.vanderbilt.edu

Annu. Rev. Public Health 2013. 34:373–96

First published online as a Review in Advance on
January 16, 2013

The Annual Review of Public Health is online at
publhealth.annualreviews.org

This article’s doi:
10.1146/annurev-publhealth-031912-114439

Keywords

safety culture, safety climate, medical errors

Abstract

Hospital errors are a seemingly intractable problem and continuing
threat to public health. Errors resist intervention because too often the
interventions deployed fail to address the fundamental source of errors:
weak organizational safety culture. This review applies and extends a
theoretical model of safety culture that suggests it is a function of inter-
related processes of enabling, enacting, and elaborating that can reduce
hospital errors over time. In this model, enabling activities help shape
perceptions of safety climate, which promotes enactment of safety cul-
ture. We then classify a broad array of interventions as enabling, enact-
ing, or elaborating a culture of safety. Our analysis, which is intended to
guide future attempts to both study and more effectively create and sus-
tain a safety culture, emphasizes that isolated interventions are unlikely
to reduce the underlying causes of hospital errors. Instead, reducing
errors requires systemic interventions that address the interrelated pro-
cesses of safety culture in a balanced manner.

373

A
nn

u.
R

ev
. P

ub
li

c
H

ea
lt

h
20

13
.3

4:
37

3-
39

6.
D

ow
nl

oa
de

d
fr

om
w

w
w

.a
nn

ua
lr

ev
ie

w
s.

or
g

A
cc

es
s

pr
ov

id
ed

b
y

W
al

de
n

U
ni

ve
rs

it
y

on
0

4/
05

/2
1.

F
or

p
er

so
na

l
us

e
on

ly
.

PU34CH22-Singer ARI 13 February 2013 23:6

INTRODUCTION

Scholarly and practitioner interest in hospital
errors—errors that result from poorly designed
and managed systems and are attributable to
the actions of multiple organizational partici-
pants who deviate from organizationally spec-
ified rules and procedures (50)—took hold
more than a decade ago with the Institute of
Medicine’s landmark report, To Err Is Human:
Building a Safer Health System (74). However,
despite a great deal of academic research and
practitioner experimentation, hospital errors
continue to present a seemingly intractable
public health problem (78), the dimensions of
which may be greater than initially imagined
(18).

A hospital’s inability to reduce these errors
stems from their organizational (123) and sys-
temic (134) nature, meaning that they are inte-
grated into complex and interrelated structures
and processes to which individuals through-
out the hospital contribute. Their causes
reside in the organization’s culture—its as-
sumptions, values, attitudes, and patterns of
behavior (130). Errors are intractable when a
culture de-emphasizes safety and instead pri-
oritizes competing concerns (e.g., cost, effi-
ciency) that can produce errors (182). A safety
culture consists of the shared values, attitudes,
and patterns of behavior regarding safety (i.e.,
concern about errors and patient harm that
may result from the process of care delivery)
(124). Culture may vary within organizations
and among their units and by professional disci-
plines. Safety climate, a related construct, refers
to shared perceptions of existing safety policies,
procedures, and practices (183). In other words,
safety climate reflects the extent to which the
organization values and rewards safety relative
to other competing priorities as demonstrated
through organizational policies and leader be-
havior (181). The expression of safety climate
in specific and identifiable policies and prac-
tices means that it captures “surface features”
of a safety culture (36).

The goal of this review is to provide a
public health and management audience with

an understanding of how a broad array of
interventions may be combined to reduce
hospital errors. Our review focuses specifically
on hospital errors because this is where the
bulk of intervention efforts have been directed
and where the measurement of errors is most
developed. To distinguish our review from
other excellent recent reviews of

interventions

designed to reduce organizational errors in the
health care context (34, 176), we focus explicitly
on interventions that reduce errors by directly
or indirectly impacting safety culture. This
allows us to categorize these activities using a
theoretical model that shows how interventions
may work together to shape safety climate and
safety culture in a process that reduces hospital
errors over time. We focus on culture rather
than errors themselves in recognition of the
importance of culture as a basic mechanism
through which patient safety is achieved (21). A
deeper understanding of the cultural underpin-
nings of errors provides a more organizational
and systemic foundation for reducing them.

An Enabling, Enacting, and
Elaborating Model of Safety Culture

We focus on safety culture as the foundation
upon which hospitals can reduce errors by pre-
venting and learning from them (120). That
is, a well-developed safety culture seeks to re-
solve the underlying causes of errors. To date,
however, the ways in which interventions shape
safety culture have been imprecisely specified.
Our review employs a recently developed con-
ceptual framework (164) to suggest that exist-
ing interventions tend to target one of three as-
pects of safety culture—enabling, enacting, or
elaborating—that when taken together create
a process with the potential to reduce hospital
errors over time. Enabling refers to leader ac-
tions that emphasize safety, enacting includes
frontline actions to surface and resolve threats
to safety, and elaborating means systematically
reflecting on and learning from performance
(164). In turn, new enabling interventions may
be selected on the basis of evolving needs
and hospital culture. Thus, cycles of enabling,

374 Singer · Vogus

A
nn
u.
R
ev
. P
ub
li
c
H
ea
lt
h
20
13
.3
4:
37
3-
39
6.
D
ow
nl
oa
de
d
fr
om
w
w
w
.a
nn
ua
lr
ev
ie
w
s.
or
g
A
cc
es
s
pr
ov
id
ed
b
y
W
al
de
n
U
ni
ve
rs
it
y
on
0
4/
05
/2
1.
F
or
p
er
so
na
l
us
e
on
ly
.

PU34CH22-Singer ARI 13 February 2013 23:6

Fewer hospital
errors

Safety cu
ltu

Safety culture

Safety cu
ltu
re
Safety cu
ltu
re
Safety culture

Safety climate
External actions:

• Accreditation and advocacy

• Surveys

• Work hours rules

Internal actions:
• Leader behaviors and

practices

• HR practices

• Technology (EMR)

Enabling
Policies and practices

that motivate the
pursuit of safety

Enacting
Frontline actions that

improve patient safety

• Interpersonal processes

(e.g., teamwork)

• Reporting and voicing

concerns

• Coordinating at care

transitions (hand overs)

and across interdependent

functions (checklists)

Shared assumptions,
values, attitudes, and
patterns of behavior

regarding safety
that become

embedded over time

Frontline
interpretations of

safety-related leader
actions and

organizational practices

• Learning-oriented

interventions

• Education (simulation)

• Operational improvement

(case-based analysis and

frontline system

improvement)

• System monitoring

(prospective, retrospective,

concurrent)

Elaborating
Learning practices that
reinforce safe behaviors

Figure 1
A cultural approach to reducing hospital errors. EMR, electronic medical record; HR, human resources. Adapted from Reference 164.

enacting, and elaborating continue iteratively
in an evolutionary process.

In applying this model to a compre-
hensive set of interventions, we make two
important refinements. First, we find that
enabling occurs not only through hospital lead-
ers but also through external actors (e.g., ac-
tivists and quasi-regulatory agencies). Second,
we posit that these enabling activities shape
frontline workers’ perceptions of safety climate
and thereby promote the enactment of safety
culture. Figure 1 depicts our theoretical model,
which highlights the interrelationships among
interventions that enable, enact, and elaborate a
culture of safety to reduce hospital errors. The
arrows in this model indicate that climate and
culture are dynamic processes.

In this review, we organize disparate
research on discrete interventions to reduce
hospital errors and apply and extend an inte-

grative model to highlight distinctions among
the interventions’ objectives. Our primary con-
tribution is the conceptual categorization of
interventions and the identification of relation-
ships among them. This is important because
the fragmented nature of prior research on hos-
pital errors provides an inadequate foundation
for practitioners to pursue more than piece-
meal solutions. Our analysis also provides re-
searchers with a richer, theoretically grounded
framework for understanding how interven-
tions combine to reduce hospital errors. We
offer practitioners a guide to more effectively
creating and sustaining safety culture. Our
review suggests that isolated interventions that
enable, enact, or elaborate a culture of safety
are unlikely to reduce the underlying causes of
hospital errors. Instead, hospital errors require
interventions that simultaneously address all
three aspects of culture rather than only one.

www.annualreviews.org • Reducing Hospital Errors 375

PU34CH22-Singer ARI 13 February 2013 23:6

This review represents a broad, albeit not
comprehensive, review of research published in
the management and health services literatures
on interventions attempting to reduce hospi-
tal errors. More specifically, in ABI/ProQuest,
PsycINFO R©, and PubMed, we searched on
the terms “safety” or “error” and “culture”
in a set of leading management, psychol-
ogy, health services, health care management,
and medical journals (see Supplemental Ap-
pendix online. Follow the Supplemental Mate-
rial link from the Annual Reviews home page at
http://www.annualreviews.org), focusing on
articles published during the most active period
of research on hospital errors (between 2000
and early 2012). We identified 593 articles. By
reviewing the abstracts of these articles, we de-
rived a list of intervention types. We next as-
signed these intervention types to an element
of the conceptual model so that each type of in-
tervention was classified primarily as enabling,
enacting, or elaborating a safety culture. We
also looked for interventions that might not fit
in the conceptual model. Then, the authors and
a research assistant each reviewed a third of the
papers to assign each one to the applicable in-
tervention type or types. We conducted a sec-
ond review to confirm the assignments. At each
stage, the group discussed interventions or pa-
pers that raised questions and jointly resolved
their classification. This allowed us to supple-
ment and refine our list of intervention types
and the relationships among them. Table 1 be-
low summarizes the literature in each category
(e.g., enabling) and subdomain (e.g., technol-
ogy). We describe the interventions designed
to promote each of the elements of the concep-
tual framework in turn.

ENABLING

Enabling a safety culture means motivating the
goal of reducing hospital errors, directing at-
tention to and prioritizing safety, and creat-
ing a context within which frontline caregivers
can enact safer practices. In reviewing these in-
terventions, two sets of mechanisms emerged:
(a) external motivators, such as regulators and

advocacy organizations, and (b) internal mo-
tivators, such as leaders and organizational
practices.

External Motivators

Researcher and practitioner interest in safety
culture as a key source for reducing hospital er-
rors took hold with the Institute of Medicine’s
To Err Is Human (74) and subsequent reports.
These early efforts to induce action tried to es-
tablish the scope of the problem (e.g., the num-
ber of deaths resulting from hospital errors) so
as to motivate remedial actions (19, 74). The
search for more accurate measures of the scope
of the problem continues (18). Administrative
data such as the Agency for Healthcare Re-
search and Quality’s patient safety indicators
(91) provide another source of data intended to
fuel change; however, some evidence suggests
that they do not predict individual hospital per-
formance (171).

Although only suggestive, there are indica-
tions that external actors can influence hospital
error reduction. For example, The Joint
Commission on Accreditation of Healthcare
Organizations has influenced hospital-level
patient safety initiatives (27), as have advocacy
organizations such as the Institute for Health-
care Improvement, the National Patient Safety
Foundation, and the Lucian Leape Institute.
Collaboratives, such as the Pittsburgh Regional
Health Initiative, also spur hospital-level efforts
to reduce hospital errors (143). The Institute
for Healthcare Improvement’s national and
international initiatives, such as the 100,000
Lives Campaign, establish goals and provide a
model for spreading improvement practices to
reduce hospital errors (90).

Other research suggests external forces, e.g.,
tort reform, may induce hospitals to focus on
reducing errors (4); however, the evidence of
their efficacy is mixed (24). Legislatures and
other policy-setting bodies are external forces
that affect health care delivery through rules re-
garding practices shown to compromise safety,
e.g., extended-duration work shifts (greater
than 12.5 h) (83). Regulations that eliminated

376 Singer · Vogus

Supplemental Material

http://www.annualreviews.org

http://www.annualreviews.org/doi/suppl/10.1146/annurev-publhealth-031912-114439

PU34CH22-Singer ARI 13 February 2013 23:6

Table 1 Interventions designed to enable, enact, and elaborate safety culture and reduce hospital errors

Intervention
category or
subdomain

Range and types
of studies Summary of findings

Examples of research gaps
and further investigation

needed
References for
sample articles

Enabling
External
motivators

There is little
systematic
investigation,
but there are
some suggestive
case studies.

Accrediting bodies (the Joint
Commission), advocacy
organizations (e.g., the Institute
for Healthcare Improvement), and
collaboratives (e.g., Pittsburgh
Regional Health Initiative) can
spur the pursuit of safety and
adoption of safer practices.

Influence of external motivators
on leader cognition and action
from direct, empirical
assessments

Effects of external motivators on
new practices and other
innovations

Accreditation
(27)

Collaboratives
(143)

Internal
motivators:
leader
characteristics
and behaviors

Most studies use
cross-sectional
survey design
with some
case-control
studies.

Studies show leader practices (e.g.,
executive WalkRounds),
behaviors (e.g., inclusiveness), and
characteristics (transformational
leadership) positively impact
safety climate.

Use different aspects of safety
climate in multiple studies

Simultaneous examination of
leader characteristics and
behaviors

Identification of the conditions
under which leader practices
are successful

Leadership
WalkRounds
(38)

Transformational
leadership (92)

Leader
inclusiveness
(105)

Internal
motivators:
HR practices

Studies
predominantly
use
cross-sectional
survey design.

Bundles of HR practices as well as
individual practices (e.g., staffing
levels) are associated with aspects
of safety climate and fewer
hospital errors.

The use of consistent,
dependent variables across
studies

Stronger research designs

Staffing (102)
HR practices

(117)

Internal
motivator:
information
technology

Most studies use
a pre/post-
intervention
design.

Numerous case
studies also
exist.

Studies of computerized physician
order entry (a) showed mixed
results for adverse drug events, (b)
showed a small positive effect on
patient safety, and (c) are
promising for bar code
verification and medication
reconciliation, but such studies
are limited.

Studies that explicitly measure
and model organizational
context and organizational
readiness for the use of
information technology

CPOE (93)
Bar code

verification
(116)

Internal
motivator:
safety climate

Most studies have
a cross-sectional
survey design.

There are some
case-control
intervention
studies.

Consistent positive effects of a
safety climate have been found on
a range of outcomes related to
hospital errors, including
infections, treatment errors,
patient safety indicators,
readmissions, error reporting, and
safety grades. Safety climate varies
across units, professions, and
organizational levels, affecting
outcomes.

The use of similar specifications
of safety climate, i.e., survey
items and modeling strategies

Longitudinal investigations to
assess the effects of change on
outcomes and to document
how hospitals can use
information about safety
climate to reduce hospital
errors

Variation and
relationship
with outcomes
(57, 63)

Enacting
Effective
interpersonal

Most studies are
quasi

Selected interpersonal behaviors
(mindful organizing and

Additional construct validation
and differentiation of related

Relational
coordination (7)

(Continued )

www.annualreviews.org • Reducing Hospital Errors 377

PU34CH22-Singer ARI 13 February 2013 23:6

Table 1 (Continued )

Intervention
category or
subdomain
Range and types
of studies Summary of findings
Examples of research gaps
and further investigation
needed
References for
sample articles

processes:
teamwork,
mindful
organizing,
relational
coordination,
and patient
involvement

experimental with
pre/post-test
design.

Many are
controlled.

Some use mixed
methods,
incorporating
interviews
alongside surveys
or other
quantitative
measures.

A few case studies
and qualitative
studies exist.

relational coordination) are
related to preventing hospital
errors and quality performance.

Ineffective interpersonal
processes yield negative
consequences, and
organizational conditions (e.g.,
culture and human factors) and
practices (e.g., hiring, training,
rewards) can promote more
effective interpersonal
processes.

Interventions to promote more
effective teamwork improve
quality, quantity, and
perception of desired
behaviors.

concepts
Direct evidence linking

interventions to reductions in
medical errors

Patient
involvement
(62)

Mindful
organization
(163)

Teamwork (166)

Reporting and
voicing
concerns

Studies have a
predominantly
cross-sectional
survey design.

Some are
questionnaire and
some scenario
based.

There are a
handful of case
studies and
longitudinal,
pre/post-
intervention
studies.

Substantial underreporting
occurs among clinicians.

Different reporting systems yield
complementary insights.

Conditions that promote
reporting include
psychological safety,
responsiveness, and closure.

Willingness to voice concerns
correlates with reduced
hospital errors.

Additional research that
specifically addresses effects of
reporting and voicing concerns
on learning and hospital errors
over time

Studies of the conditions under
which learning is more likely to
occur

Complementary
insights (80)

Underreporting
(108)

Coordination at
care transitions
and across
interdependent
functions:
checklists,
standardized
protocols, and
others

There is a large
mix of pre/post-
intervention
studies,
sometimes
controlled, and a
handful of case
studies and
cross-sectional
observational
studies, with one
claims-based
analysis.

Checklists and structured
communication improve safe
practices and reduce M&M;
however, implementation
varies.

Longitudinal, randomized, and
controlled studies of
intervention effectiveness

Studies that directly examine
how supportive (e.g., climate)
and inhibiting conditions
interact with specific protocols
to reduce hospital errors

Checklists (59)
Hand overs (110)

(Continued )

378 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6
Table 1 (Continued )
Intervention
category or
subdomain
Range and types
of studies Summary of findings
Examples of research gaps
and further investigation
needed
References for
sample articles

Elaborating
Learning-
oriented
interventions

These studies are
predominantly
case controlled or
qualitative with a
handful of cross-
sectional survey
studies and a
small number of
longitudinal
studies.

Learning can improve
performance and prevent
future errors.

Studies identify facilitators (e.g.,
psychological safety) and
barriers (e.g., ambiguous
threats) to learning and
recommend strategies that
promote learning in groups
and organizations.

Descriptions of factors that
promote or undermine
learning

Identification of interventions
that create the conditions that
promote effective learning and
demonstrations of their ability
to reduce future errors

Investigations of how and under
what conditions these
interventions affect the
processes of enabling and
enacting

Longitudinal
study (148)

Learning from
reported errors
(150)

Education The studies are of
predominantly
pre-/posttest
design with a
large number of
studies taking a
mixed methods
approach.There
are a handful of
qualitative
studies.

Education is a popular
technique, alone or in
combination with other
interventions, to reduce
medical errors.

Simulation is an increasingly
popular mode of education.

Multiple descriptive studies
Studies of the comparative

effectiveness of differing
educational interventions for
shaping culture and reducing
hospital errors over time

Studies of the organizational
factors that enhance or inhibit
educational interventions

Education alone
(47)

Multimode
including
simulation (140)

Operational
improvements:
industrial
techniques,
frontline
systems
improvement,
and
infrastructure
improvement

The studies are
predominantly of
pre-/posttest
design, often
employing mixed
methods.

There are a fair
number of
cross-sectional
survey studies and
a limited number
of longitudinal
studies, often
with limited
sample sizes.

Hospitals have successfully
applied principles from
industrial production to
improve process reliability.

Frontline workers are uniquely
positioned to identify and
resolve problems that
contribute to hospital errors
but tend to compensate for
rather than resolve them.

Thus, frontline involvement in
systemic improvement must be
fostered.

Internal committees and
external collaboratives provide
motivation and resources to
support sustained
improvement activity.

Such infrastructure has been
associated with performance
improvement.

Literature lacks
information about
comprehensive, sustainable
programs that show how
longitudinal improvement can
be achieved

Studies involving infrastructure
improvements and their effects
on hospital errors

Operational
improvement
(69)

External
infrastructure
(104)

Internal
infrastructure
(115)

Frontline system
improvement
(157)

(Continued )

www.annualreviews.org • Reducing Hospital Errors 379

System
monitoring:
prospective,
retrospective,
and concurrent
reviews

These studies in
general use
cross-sectional,
pre-/post-survey
or intervention
longitudinal
designs with
some case studies.

Prospective (e.g., FMEA),
retrospective (e.g., root cause
analysis, M&M), and
concurrent (e.g., compliance
monitoring) analytical
strategies are used to identify
and prioritize the means to
prevent future hazards.

Results often depend on whether
hospitals conduct these
activities in a nonpunitive
manner.

Studies of direct evidence of
impact on hospital errors

Studies of prospective and
concurrent processes for
influencing safety culture and
reducing errors

Concurrent (85)
Prospective (94)
Retrospective

(152)

Abbreviations: CPOE, computerized physician order entry; FMEA, failure mode and effects analysis; HR, human resources; M&M, mortality and
morbidity.

extended work shifts and reduced the number of
hours worked per week reduced attention fail-
ures (84) and serious medical errors by interns
(79), but subsequent duty-hour reforms have
had no impact on safety outcomes (126).

There is some evidence that using pub-
lished research to guide practice (158) and
ongoing practitioner partnerships with leading
researchers [e.g., Michigan’s Keystone Initia-
tive (118)] builds safety culture and reduces hos-
pital errors. There is also growing use of sur-
veys to measure, motivate, and direct initiatives
to improve safety climate and reduce hospital
errors (107).

Internal Motivators

Leader characteristics and behaviors.
Leader characteristics and behaviors work to
reduce hospital errors through enabling and
shaping perceptions of safety climate. Trans-
formational leadership—providing an inspiring
vision and fostering identification with it—is
the leader characteristic most strongly associ-
ated with improving safety culture and safety
outcomes (92), and transformational leadership
can also be taught (96).

A wide array of leader behaviors and their
impact on safety climate and hospital errors

have been explored. The personal practice of
leaders has a strong and consistent impact on
safety climate. For example, leaders who per-
sonally disseminate safety information and pro-
vide a model of safe behavior (6) improve safety
climate. In addition, related leader behaviors,
including attempts to change language [e.g., in-
vestigations of errors becomes the analysis of
accidents (31)] and be more inclusive of others
(105), enhance employee engagement in cre-
ating a safety culture (155). An empowering
leadership style (179) that includes coaching
(32), dynamic delegation to junior members of a
team (71), and candid conversation among team
members (135) also positively affects safety
culture.

Other specific interventions that feature
leader behaviors include interactions with
frontline caregivers regarding patient safety is-
sues, frontline safety forums (159), Leadership
WalkRoundsTM (38), patient safety rounding
(87), and adopt-a-work unit (122). Zohar &
Luria (184) experimented with a direct ap-
proach for changing leader behavior and
strengthening safety climate. Specifically,
frontline managers received weekly feedback
concerning their safety-oriented interactions
with subordinates, and upper-level managers

380 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

received similar feedback as well as data on
the frequency of employees’ safety behaviors.
Safety-oriented interaction increased both
manager and employee ratings of safety
climate. Safety climate is also improved by
integrated bundles of safety practices (e.g., the
comprehensive unit safety program), including
active measurement of safety climate, safety
education, mechanisms for identifying and
addressing staff concerns, and extensive senior
executive involvement (e.g., adopt-a-work unit
programs) (121).

Human resource practices. Human resource
(HR) practices create the conditions under
which a skilled workforce is developed (e.g.,
through careful selection, extensive and on-
going training, and adequate staffing) to re-
duce hospital errors and sufficiently empow-
ered to capitalize on these skills. Such work
practices were shown to improve the quality
of information shared and to reduce medica-
tion errors (117). A similar set of practices
was associated with reductions in mortality
from errors (172). Additional research has fo-
cused on the impact of a single HR practice
(e.g., staffing/workload or training) on safety
climate and hospital errors. Studies of nurse-
to-patient ratios find that adequate staffing is
associated with fewer adverse events (2, 102).
In contrast, less adequate staffing levels (in-
dicated by workload, overtime, or increased
nonregistered nurse hours of care) resulted in
unexpected deaths (28) and medication errors
(132).

Technology. Research has identified infor-
mation technology as an important mechanism
for enabling safety culture, but at the same
time, its efficacy in reducing hospital errors is
heavily dependent upon the organization’s cul-
tural readiness to make use of it. Two of the
most researched technologies are computer-
ized physician order entry (CPOE) and elec-
tronic medical records. Some large-scale stud-
ies, simulations, and systematic reviews suggest
that implementation of such technologies re-
mains slow, fatal orders are inconsistently de-

tected (93), and new errors are introduced by
CPOE (75). However, there is also sugges-
tive evidence that these systems can substan-
tially reduce medication errors (67). Although
a recent review concluded that the effect of
CPOE on adverse drug events is mixed (175),
others show that CPOE is an improvement
over educational interventions (44). Electronic
medical records have been shown to have a
small positive effect on patient safety (113),
whereas other information systems, including
electronic medication reconciliation systems (1)
and bar code verification technology (116), have
demonstrated stronger effects, albeit on a more
limited scale. The efficacy of such initiatives
importantly depends upon the organization’s
readiness to adopt the technology (147) and the
implementation process (77).

SAFETY CLIMATE

We treat safety climate as the key mecha-
nism through which enabling promotes enact-
ing and, in turn, safety. Specifically, we sug-
gest that frontline provider interpretations of
safety-relevant leader and organizational prac-
tices constitute safety climate, and their per-
ceptions of safety climate influence their safety
behaviors.

Safety climate perceptions are commonly
tied to a local leader’s commitment to safety
(e.g., through safety practices, procedures, and
other resources committed to safety), prior-
ity placed on safety (i.e., the extent to which
safety is subordinated to other goals), and
dissemination of safety information (66). For
example, a supervisor who disregards safety
procedures whenever production falls behind
schedule or who punishes people for mis-
takes signals a low commitment to safety
(14). More recent research has expanded the
dimensions of safety climate to include man-
agement/supervisors, safety systems, risk per-
ception, job demands, encouragement of re-
porting/speaking up, safety attitudes/behaviors,
communication/feedback, teamwork, personal
resources (e.g., stress), and other organizational
factors (36).

www.annualreviews.org • Reducing Hospital Errors 381

PU34CH22-Singer ARI 13 February 2013 23:6

Frontline staff perceptions of safety climate
have been found to predict fewer treatment er-
rors, fewer infections (63), fewer readmissions
for heart failure and acute myocardial infarction
patients (57), lower incidences of preventable
complications (141), and a better patient safety
grade (33).

The effects of a leader’s personal safety prac-
tices on treatment errors are amplified when
they are paired with an organization-wide pri-
ority on safety (66). Safety climate, as indicated
by suitable safety procedures and clear informa-
tion flow, reduced treatment errors only when
leaders emphasized safety and gave it a high pri-
ority (100). Perception of a strong safety climate
results in improved safety performance because
it increases safety motivation (i.e., willingness
to exert effort), participation in voluntary safety
activities (e.g., helping coworkers with safety-
related issues and attending safety meetings)
(101), adherence to safety protocols, employee
reporting of errors and incidents (99), and cre-
ative problem solving (63, 141).

However, perceptions of safety climate are
rarely shared across an organization. In fact, nu-
merous studies find that the perception of safety
climate varies based on one’s position in the or-
ganizational hierarchy [i.e., administrators tend
to see higher levels of safety climate than front-
line caregivers (137)], professional affiliation
[i.e., doctors perceive higher levels of safety
climate than do nurses on dimensions such as
teamwork and support/recognition of safety ef-
forts (58)], and medical specialty or unit [e.g.,
emergency department personnel perceive a
weaker safety climate (138)]. Importantly, the
discrepancies in perceptions of safety climate
are also consequential for safety outcomes. For
example, frontline staff ’s perceptions of safety
climate have been associated with patient safety
indicators, whereas those of senior managers
were not (127, 141).

ENACTING

Enacting a safety culture that reduces hospi-
tal errors means frontline health care providers
consistently translate safety policies and guide-

lines into routine practice. Enacting safety cul-
ture requires identifying and reducing latent
and manifest threats to safety. To accomplish
this, organizations must confront communica-
tion failures, including the failure to transmit
information about vulnerabilities and mistakes.
Research suggests that enacting a safety cul-
ture reduces errors when enacting consists of
deliberate efforts such as engaging caregivers
and patients in effective interpersonal processes
(i.e., teamwork, mindful organizing, and rela-
tional coordination), promoting regular report-
ing and voicing concerns, and deploying check-
lists and standardized protocols to coordinate
care when transitions occur.

Interpersonal Processes

Teamwork. Teamwork among health care
providers is considered both an important com-
ponent of a culture of safety and an essential
ingredient for reducing medical errors. Defini-
tions and frameworks for thinking about team-
work are plentiful, as are measures of teamwork
(160). Qualitative research has highlighted the
consequences of poor teamwork on hospital er-
rors (151). Qualitative studies have also iden-
tified conditions (129) and practices (41) that
inhibit or promote effective teamwork. In ad-
dition, the literature describes a variety of in-
terventions to improve teamwork. The most
prevalent of these are education-based team
training initiatives, such as crew resource man-
agement (68) and TeamSTEPPS (166). They
have been found to positively impact the quan-
tity and quality of communication and team-
work behaviors as well as safety and team-
work climates. These team training programs,
which aim to cultivate enhanced communi-
cation and coordination within teams, use a
variety of intervention modalities, including
simulation-based training (23). Training pro-
grams may have a single focus (64) or have
a multidisciplinary focus. Many programs in-
clude teamwork training as an essential com-
ponent of a multipronged program, combining
it with checklists (17), patient communication
(10), leadership (109), and policy initiatives (5).

382 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

Mindful organizing. According to Weick &
Sutcliffe (167), mindful organizing consists of
five interrelated organizational processes: pre-
occupation with failure, reluctance to simplify
interpretations, sensitivity to operations, com-
mitment to resilience, and deference to exper-
tise. High-reliability organizations, which op-
erate technically complex systems in a nearly
error-free manner over long periods, enact
these processes (72). Case studies of organi-
zational disasters suggest that the absence of
mindful organizing was a major contributing
factor (168). Consequently, developing mind-
fulness among frontline workers to prevent er-
rors becomes a priority (125). There have been
efforts to build mindful organizing in hospi-
tal units (87) and to measure and improve it
using surveys (162). Evaluations have demon-
strated that increased mindful organizing re-
sults in fewer errors and patient falls (162), es-
pecially when paired with trusted leaders and
structured protocols, e.g., care pathways (163).

Relational coordination. Relational coordi-
nation is a term broadly encompassing strate-
gies focused on improving communication and
relationships among individuals whose roles re-
quire them to work together to integrate tasks
(48). Studies have associated relational climate
with adherence to recommended practices (7).
Adherence to protocols is associated with oper-
ational reliability that makes error-free perfor-
mance more likely. Some efforts have sought to
improve relational coordination (88) and to de-
scribe conditions (e.g., use of HR practices) that
make relational coordination more likely (49).
Additional research suggests that relational co-
ordination may be more important when task
and cognitive loads are greater (35).

Patient involvement. Long-standing re-
search suggests that patients can play an
important role in reducing medical errors by
helping to more quickly detect and correct er-
rors, but only if the organization is open to and
supportive of their involvement. Researchers
have identified and assessed strategies for
effectively engaging patients that range from

having patients ask questions about their health
and treatment to actively managing and coordi-
nating their own care (62, 170). They also have
identified conditions that enhance the likeli-
hood of successful patient involvement; these
include self-efficacy, preventability of incidents,
and effective actions (131). Several studies have
explored the potential for information tech-
nologies to promote more effective patient-
provider communication, suggesting the use of
technology as a means to strengthen data gath-
ering, diagnosis verification, and patient follow-
up and monitoring among adults (142), partic-
ularly for vulnerable populations (106). Studies
exploring the potential for patient involvement
also have examined the accuracy of patient-
reported events with mixed results (146, 180).

Reporting and Voicing Concerns

The extensive literature on incident reporting
suggests that policy makers and practitioners
believe this strategy has the potential for re-
ducing medical errors. In fact, reporting and
a reporting culture are seen as building blocks
for patient safety (74) and safety culture (124).
Research in hospitals has examined the accu-
racy, comprehensiveness, and sufficiency of re-
porting; the information derived from report-
ing; the conditions under which it occurs; and
its effect on errors. Several scholars have pro-
posed frameworks or typologies for detect-
ing and reporting errors (128, 145). Various
studies document substantial underreporting of
incidents among clinicians (108) and explore
reasons for failing to report (61). Research com-
paring information obtained through different
reporting systems (80) has found that the infor-
mation obtained may be redundant (52). In the
majority of instances, however, different
perspectives provide complementary insights
about organizational safety, thus warranting
a portfolio of reporting systems. For exam-
ple, communication problems were common
from patient complaints, whereas WalkRounds
tended to identify issues with equipment and
supplies. A few papers look beyond incident re-
porting by describing strategies for analyzing,

www.annualreviews.org • Reducing Hospital Errors 383

PU34CH22-Singer ARI 13 February 2013 23:6

addressing (43), and learning from (150) re-
ported incidents. These papers highlight the
need for responsiveness and closure to reap
benefits from and cultivate continued report-
ing. Additional studies have treated a clinician’s
willingness to voice concerns as an independent
variable, correlating higher levels of voiced con-
cerns with reduced hospital errors and other
outcomes (99).

Coordinating at Care Transitions and
Across Interdependent Functions

Checklists. Among lessons the health care
sector has learned from aviation is that check-
lists have the potential to improve the con-
sistency of safe practices as well as commu-
nication and teamwork, thereby promoting
error-free results (45). Effective checklist use,
however, requires the perception that the or-
ganization embraces them (120). A growing
body of evidence suggests that checklists can
improve patient safety (73). Although com-
monly applied in intensive care units (12) and
surgery (25, 59), studies also describe check-
list use in emergency departments, acute care
settings, medication administration (44), and
as part of multipronged programs (174). In
practice, however, checklist use varies once
adopted, presenting an obstacle to deriving
benefits (98). A few studies explore barri-
ers to checklist use (37) and characteristics
of implementation processes that promote
it, including the ability of leaders to persuasively
explain why and how to use the checklist (20).
Other reports provide suggestions for develop-
ing medical checklists (56) and describe surveys
that measure the factors associated with effec-
tive checklist implementation (16).

Hand overs. The transition of patients be-
tween care settings and the sequential exchange
of information between clinicians caring for
the same patients both present opportunities
for error and require effective management to
avoid them. Evidence demonstrates that poor
hand overs result in errors both within (97)
and between (76) specialties. Interventions have

shown promise in improving hand overs by re-
ducing information omissions, technical errors,
and preventable adverse events include an ed-
ucation curriculum (11), checklists (15), and
structured interdisciplinary rounds (110).

Others. Myriad additional opportunities exist
for enacting a safety culture to reduce hospital
errors (133). Research has shown that physi-
cian participation is positively associated with
improvement in hospital patient safety indica-
tors, but involvement by multiple hospital units
in the improvement effort is associated with
worse values on this and other quality measures
(169). Efforts specifically focused on standard-
izing aspects of health care delivery also have
been shown to reduce errors (177). In addition,
studies have demonstrated potential benefits for
patient safety from time management (3), risk
management (13), and remediation, i.e., disclo-
sure (40) and apology (60). The literature also
highlights common conditions that contribute
to the inability of hospitals to reduce errors,
such as health care worker stress and burnout
(173) and the practice of work-arounds (55).

ELABORATING

Elaborating a safety culture is the systematic
process of reflecting and translating prior ex-
perience to spread and refine manager and
frontline employee safety-oriented behaviors
and practices that have been previously en-
abled and enacted. Elaboration refers to the
evolutionary expansion of these behaviors and
practices, preferably characterized by increas-
ing tolerance for them and growing capabili-
ties for addressing complications that may ac-
company them. Interventions that promote the
elaboration of a safety culture include those that
promote learning, education, operational im-
provement, and system monitoring.

Learning-Oriented Interventions

Learning from small failures through experi-
mentation presents health care organizations
with the opportunity to prevent problems that

384 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

have the potential to cause patient deaths (144).
Learning also has been credited with the suc-
cessful transfer and retention of best prac-
tices (8). Considerable attention has been given
to identifying the facilitators of learning from
errors, and most notable among them is psycho-
logical safety—a belief that the group environ-
ment is safe for taking interpersonal risks (29).
Studies also have identified barriers to learning
(153) and conditions under which learning is
less likely, such as when a problem is ambiguous
(30). Organizations may learn from frontline
workers’ complaints about operational prob-
lems (157), briefings and debriefings (161), inci-
dent reporting systems (86, 150), and mortality
and morbidity (M&M) conferences (111). Sur-
vey measures also provide organizations with
opportunities to assess the extent to which they
are learning organizations (139) and learn from
reported events (46).

Education

Education is a popular feature of many inter-
ventions designed to reduce hospital errors.
Several interventions have used educational ini-
tiatives to promote safety culture, some with
positive effects (47). Education is frequently
a component of multipronged interventions
and has been used in combination with team-
work, leadership, frontline system improve-
ment, technology, incident reporting, patient
partnership, checklists, and measurement and
feedback programs to improve safety culture
(5, 118). More specifically, simulation is be-
coming an increasingly popular mode for in-
troducing practices and processes for shaping
safety culture and reducing hospital errors, but
current evidence of its effects is mixed (22,
23, 81). Studies have identified how safety and
team-based training for medical students (70),
frontline caregivers (125), and leaders (140)
changes behavior (e.g., more learning oriented)
and reinforces safety culture. They also have
demonstrated that, in the context of academic
medicine, faculty and students must manage a
trade-off between education and patient safety
(95).

Operational Improvements

Industrial techniques. Recognizing that op-
erational failures can contribute not only to ex-
cess costs but also to safety problems, experts
recommend applying principles from industrial
production for clarifying and streamlining op-
erations and reducing controllable variations to
enhance reliability and reduce hospital errors
(82). Such techniques, including the Toyota
Production System and lean manufacturing
principles, have been successfully implemented
across organizations, notably at the Virginia
Mason Medical Center in Seattle (69) and
ThedaCare Appleton Medical Center in Apple-
ton, Wisconsin (154). Evidence suggests these
programs have improved problem resolution
(39) and the timeliness and reliability of care
processes (178).

Frontline system improvement. Given the
unique and expert perspective of frontline
workers on safety hazards in hospitals (159),
scholars and policy makers advocate training,
trusting, and supporting them to identify
and resolve safety problems (9). Studies
present models for understanding frontline
problem-solving behavior (157) and programs
for identifying and monitoring problems to
improve problem solving and patient safety
(149). They also describe how improvement
efforts can reduce work-arounds (54) and im-
prove policy compliance (89). Frontline system
improvement often plays a prominent role in
multipronged approaches, such as the compre-
hensive unit safety program, which has been
credited with improvements in safety culture
(118). However, substantial research also
suggests frontline system improvement must
be fostered because frontline workers tend to
compensate for failures rather than treat them
as learning opportunities (156). Leadership
turnover can also undermine improvement
initiatives (115).

Improvement infrastructure. Research also
highlights the importance of maintaining the
infrastructure to support safety initiatives

www.annualreviews.org • Reducing Hospital Errors 385

PU34CH22-Singer ARI 13 February 2013 23:6

because it is necessary to catalyze, execute,
and sustain efforts to reduce hospital errors.
Internally focused, safety-oriented committees
provide a systematic approach to identifying
and supporting efforts to improve and main-
tain safety and safety culture (115). Similarly,
externally driven improvement collaboratives
provide participants with a forum, motiva-
tion, and social support as well as project
management and process-improvement skills
to execute improvement activities in their or-
ganizations (103). Collaborative approaches
also have been recommended for the pri-
oritization and resolution of safety hazards
that lend themselves to industry-wide so-
lutions (119). Research shows that perfor-
mance improvement increases with the use of
both internal and external learning activities
(104).

System Monitoring

The literature describes a variety of strategies—
prospective, retrospective, and concurrent—for
enriching our understanding of delivery sys-
tems and promoting a safety climate and safe
practices throughout an organization.

Prospective review. Prospective strategies
include failure mode and effects analysis
(FMEA), prospective hazard analysis, and hu-
man factors engineering. FMEA and other
forms of prospective hazard analysis ask prac-
titioners to identify potential hazards and rate
their severity and likelihood to design processes
that prevent them. These techniques have been
applied to a broad range of care processes alone
(26) and as part of multipronged programs
(136), used to prioritize interventions (65), and
credited with reducing medical errors (94). Hu-
man factors engineering applies an understand-
ing of the cognitive and behavioral limitations
of human beings to system design. Studies have
demonstrated the ability of this discipline to
develop safe, comfortable, and effective equip-
ment and systems through iterative tests and
refinements (51).

Retrospective review. Retrospective analy-
sis in hospitals usually takes the form of root
cause analysis, a structured approach to identi-
fying the factors that resulted in a harmful out-
come. Predicated on the belief that addressing
the causes of past problems may prevent fu-
ture problems, studies have demonstrated the
importance of conducting these analyses to
identify multiple approaches and shape clini-
cian workflow in the name of reducing hos-
pital errors (42). These are often combined
with stories of dramatic events that can en-
gage clinicians to consider the system prob-
lems that cause them, thus reinforcing a safety
culture. For example, the long-standing Annals
of Medicine case-based series, the Agency for
Healthcare Research and Quality-sponsored
“WebM&M,” and M&M rounds have engaged
caregivers in disclosing and collective learning
from specific events (165). M&M conferences
are also widespread among teaching hospitals
(112). However, many clinicians are reluctant
to openly discuss errors in a conference setting
(114). Research has offered suggestions for pro-
moting enhanced learning from M&M confer-
ences (111, 112), including making the organi-
zation’s stance toward errors explicit, selecting
cases that present learning opportunities, using
skilled moderators to facilitate discussion, en-
couraging broad attendance, and focusing on
generalizable lessons. Implementing such pro-
grams has been associated with improvement in
safety climate (152).

Concurrent review. Compliance monitoring
is a form of concurrent analysis involving the
collection and analysis of information on the
performance of programs or protocols fol-
lowing initial implementation. Studies have
demonstrated methods for compliance moni-
toring (e.g., real-time, clandestine observation)
and their value for continuous improvement of
care processes and protocols (85).

DISCUSSION

In this review, we distilled research on interven-
tions to reduce hospital errors into a framework

386 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

that captures the varied ways in which they op-
erate through processes of enabling, enacting,
or elaborating a safety culture. Although the
assembled evidence suggests support for the
effects of interventions on safety climate and
safety culture, evidence is weaker for reducing
hospital errors. As identified in earlier reviews
(176), this is undoubtedly, in part, a function
of the organizational and systemic nature
of hospital errors, which makes it difficult to
conceptualize and measure them and erects nu-
merous barriers to implementing interventions.

At the same time, the modest effects of var-
ied interventions on reducing hospital errors
suggest a key contribution of our review: rec-
ognizing that the systematic pursuit of en-
abling, enacting, and elaborating—not isolated
interventions—offers the greatest potential for
reducing hospital errors. In addition, as our
adapted conceptual model implies, a hospital
can never be fully error free. However, ongo-
ing and iterative processes of enabling, enact-
ing, and elaborating a safety culture can reduce
and minimize hospital errors.

Implications for Research and Practice

The main implication of our adapted concep-
tual model is that the starting point for con-
sidering future interventions should resemble
what we have identified as multipronged ap-
proaches. These would intentionally address
the organization’s ability to enable, enact, and
elaborate a safety culture rather than focus on
just one of these areas. For example, if an or-
ganization or unit was going to intervene to in-
crease teamwork (which we have identified as
a form of enacting), it would mean considering
how teamwork could be enabled through leader
support and organizational practices (e.g., ad-
equate staffing to allow for training and other
exercises during work hours) and how it could
be elaborated by disseminating the plan to other
groups and refining the intervention over time.
Once initiated, teamwork interventions might
be further enabled by policies that reward team-
based care. This interpretation of our model
also suggests a more holistic approach to asking

research questions and the means of answering
them.

Another important implication of our
adapted model is that interventions will be more
successful when implemented in a culturally
sensitive manner. Not all interventions will be
useful and appropriate in all settings (a po-
tentially important explanation for the mixed
findings observed for many interventions). The
ability to discover interventions that can work
within an organization’s existing culture relies
on, and is an underappreciated aspect of, leader-
ship. It requires understanding the fundamen-
tal mechanisms through which the intervention
is expected to achieve change and reconciling
these to the basic shared beliefs and assump-
tions held by organizational members. This im-
plication is consistent with studies that have
explained previous failures to spread improve-
ment interventions (e.g., total quality manage-
ment) as a result of leaders’ failures to funda-
mentally change the motivational structure of
the work (53).

Above, we have described the large and
growing literature on safety climate as bridg-
ing the enabling and enacting of a safety cul-
ture. One persistent finding in this literature is
that an organization-level safety climate is elu-
sive. Instead, there is considerable evidence that
climate is fragmented across professions, orga-
nizational levels, and organizational subunits.
This raises the important question of when (if
ever) a hospital-level safety climate (and cul-
ture) emerges. Are climate perceptions more
likely to be shared when many, if not all, of the
enabling conditions we identified are present?
Or are some factors (e.g., leader practices) es-
pecially important?

Lastly, Table 1 suggests a number of impor-
tant research questions, the answers to which
will further refine the proposed model and
better establish the linkages among interven-
tions, culture, and hospital errors. For exam-
ple, we need more systematic research on ex-
ternal motivators. What external actors or poli-
cies motivate hospitals to pursue efforts that
have demonstrated impacts on reducing hos-
pital errors? Future research should also more

www.annualreviews.org • Reducing Hospital Errors 387

PU34CH22-Singer ARI 13 February 2013 23:6

carefully and consistently operationalize a num-
ber of the concepts we identified in our model,
including safety climate, HR practices, and
teamwork.

In addition, as previously established (34,
176), our review finds that a rigorous, quantita-
tive demonstration of the relationship between
an intervention and outcomes remains rare.
Although one could easily dismiss research
designs other than randomized clinical trials
as less rigorous and call for stronger analytical
methods for evaluation, our investigation sug-
gests some caveats to this typical conclusion.
Our model suggests that intervening in ways
that are sensitive to the existing culture and that
attempt to shape the culture through system-
ically enabling, enacting, and elaborating will
be most effective. Holding organizational in-
terventions to a “gold standard” could result in
the application of validated interventions that
neither fit a particular organization nor span
the full enabling, enacting, and elaborating
cycle. Quantitative studies of the relationships
between interventions and outcomes, espe-
cially when controlling for prior performance
through structural equation modeling or
other rigorous approaches, should constitute

evidence for diffusing an intervention under
appropriate conditions. Combining these stud-
ies with those that directly assess the contextual
conditions under which interventions—from
voice to leadership behaviors to education
and learning—are most effective for reducing
hospital errors (i.e., moderators that enhance
the relationship) is also needed. Finally, we
need additional longitudinal, mixed methods
and qualitative investigations—including
ethnography and case comparisons—that
identify the mechanisms through which an
intervention leads to fewer hospital errors.

CONCLUSION

Faced with the persistent challenge of hospi-
tal errors, policy makers and practitioners need
guidance regarding how to achieve improve-
ment. We have argued that piecemeal initiatives
are inadequate and that strengthening safety
culture necessitates interventions that simul-
taneously enable, enact, and elaborate it in a
way that is attuned to the existing culture. This
approach may hold the key to demonstrably
reducing hospital errors and ultimately saving
lives.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.

ACKNOWLEDGEMENT

The authors thank Ingrid Nembhard and Kathleen Sutcliffe for comments that substantially
improved the contribution and clarity of our paper. We also thank Mathew Kiang for his expert
research assistance.

LITERATURE CITED

1. Agarwal S, Frankel L, Tourner S, McMillan A, Sharek PJ. 2008. Improving communication in a pediatric
intensive care unit using daily patient goal sheets. J. Crit. Care 23:227–35

2. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J. 2002. Hospital nurse staffing and patient mortality,
nurse burnout, and job dissatisfaction. JAMA 288(16):1987–93

3. Amalberti R, Brami J. 2012. “Tempos” management in primary care: a key factor for classifying adverse
events, and improving quality and safety. BMJ Qual. Saf. 21:729–36

4. Annas GJ. 2006. The patient’s right to safety—improving the quality of care through litigation against
hospitals. N. Engl. J. Med. 354(19):2063–66

388 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

5. Arriaga AF, Elbardissi AW, Regenbogen SE, Greenberg CC, Berry WR, et al. 2011. A policy-based
intervention for the reduction of communication breakdowns in inpatient surgical care: results from a
Harvard surgical safety collaborative. Ann. Surg. 253(5):849–54

6. Barling J, Loughlin C, Kelloway EK. 2002. Development and test of a model linking safety-specific
transformational leadership and occupational safety. J. Appl. Psychol. 87(3):488–96

7. Benzer JK, Young G, Stolzmann K, Osatuke K, Meterko M, et al. 2011. The relationship between
organizational climate and quality of chronic disease management. Health Serv. Res. 46(3):691–711

8. Berta WB, Baker R. 2004. Factors that impact the transfer and retention of best practices for reducing
error in hospitals. Health Care Manag. Rev. 29(2):90–97

9. Berwick DM. 2003. Improvement, trust, and the healthcare workforce. Qual. Saf. Health Care 12(6):448–
52

10. Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RM. 2010. Improving safety
culture on adult medical units through multidisciplinary teamwork and communication interventions:
the TOPS Project. Qual. Saf. Health Care 19(4):346–50

11. Bray-Hall S, Schmidt K, Aagaard E. 2010. Toward safe hospital discharge: a transitions in care curriculum
for medical students. J. Gen. Intern. Med. 25(8):878–81

12. Byrnes M, Schuerer D, Schallom M, Sona C, Mazuski J, et al. 2009. Implementation of a mandatory
checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive
care unit practices. Crit. Care Med. 37:2775–81

13. Cagliano AC, Grimaldi S, Rafele C. 2011. A systemic methodology for risk management in healthcare
sector. Saf. Sci. 49(5):695–708

14. Carroll J, Quijada M. 2004. Redirecting traditional professional values to support safety: changing or-
ganisational culture in health care. Qual. Saf. Health Care 13(Suppl. 2):ii16–21

15. Catchpole K, de Leval M, McEwan A, Pigott N, Elliott M, et al. 2007. Patient handover from surgery
to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr.
Anaesth. 17(5):470–78

16. Chan KS, Hsu Y-J, Lubomski LH, Marsteller JA. 2011. Validity and usefulness of members reports of
implementation progress in a quality improvement initiative: findings from the Team Check-up Tool
(TCT). Implement. Sci. 6:115

17. Chase D, McCarthy D. 2010. Case study: sustaining a culture of safety in the U.S. Department of Veterans
Affairs Health Care System. Commw. Fund Rep. Quality Matters. http://www.commonwealthfund.
org/Newsletters/Quality-Matters/2010/April-May-2010/Case-Study.aspx

18. Classen DC, Resar R, Griffin F, Federico F, Frankel T, et al. 2011. “Global trigger tool” shows that
adverse events in hospitals may be ten times greater than previously measured. Health Aff. 30(4):581–89

19. Comm. Qual. Health Care Am. 2001. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: Inst. Med./Natl. Acad. Press

20. Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. 2011. Effective surgical safety checklist
implementation. J. Am. Coll. Surg. 212(5):873–79

21. Cook R, Rasmussen J. 2005. “Going solid”: a model of system dynamics and consequences for patient
safety. Qual. Saf. Health Care 14:130–34

22. Cooper JB, Singer SJ, Hayes J, Sales M, Vogt J, et al. 2011. Design and evaluation of simulation scenarios
for a program introducing patient safety, teamwork, safety leadership and simulation to healthcare leaders
and managers. Simul. Healthc. 6(4):231–38

23. Cooper JB, Blum RH, Carroll JS, Dershwitz M, Feinstein DM, et al. 2008. Differences in safety climate
among hospital anesthesia departments and the effect of a realistic simulation-based training program.
Anesth. Analg. 106(2):574–84

24. Davis P, Lay-Yee R, Briant R, Scott A. 2003. Preventable in-hospital medical injury under the “no fault”
system in New Zealand. Qual. Saf. Health Care 12(4):251–56

25. de Vries EN, Prins HA, Crolla RMPH, Outer den AJ, van Andel G, et al. 2010. Effect of a comprehensive
surgical safety system on patient outcomes. N. Eng. J. Med. 363(20):1928–37

26. Dean JE, Hutchinson A, Escoto KH, Lawson R. 2007. Using a multi-method, user centred, prospective
hazard analysis to assess care quality and patient safety in a care pathway. BMC Health Serv. Res. 7:89

www.annualreviews.org • Reducing Hospital Errors 389

http://www.commonwealthfund.org/Newsletters/Quality-Matters/2010/April-May-2010/Case-Study.aspx

PU34CH22-Singer ARI 13 February 2013 23:6

27. Devers KJ, Pham HH, Liu G. 2004. What is driving hospitals’ patient-safety efforts? Health Aff. 23(2):
103–15

28. Diwas S, Terwiesch C. 2009. Impact of workload on service time and patient safety: an econometric
analysis of hospital operations. Manag. Sci. 55(9):1486–98

29. Edmondson A, Cannon M. 2005. Failing to learn and learning to fail (intelligently): how great organi-
zations put failure to work to improve and innovate. Long Range Plan. 38(3):299–319

30. Edmondson A, Roberto MA, Bohmer RM, Ferlins EM, Feldman L. 2004. The recovery window: orga-
nizational learning following ambiguous threats in high-risk organizations. In Organization at the Limit:
NASA and the Columbia Disaster, ed. M Farjoun, WH Starbuck. London: Blackwell

31. Edmondson AC. 2004. Learning from mistakes is easier said than done: group and organizational influ-
ences on the detection and correction of human error. J. Appl. Behav. Sci. 40(1):66–90

32. Edmondson AC, Bohmer RM, Pisano GP. 2001. Disrupted routines: team learning and new technology
implementation in hospitals. Adm. Sci. Q. 46(4):685–716

33. El-Jardali F, Dimassi H, Jamal D, Jaafar M, Hemadeh N. 2011. Predictors and outcomes of patient safety
culture in hospitals. BMC Health Serv. Res. 11:45

34. Etchells E, Koo M, Daneman N, McDonald A, Baker M, et al. 2012. Comparative economic analyses
of patient safety improvement strategies in acute care: a systematic review. BMJ Qual. Saf. 21(6):448–56

35. Faraj S, Xiao Y. 2006. Coordination in fast-response organizations. Manag. Sci. 52(8):1155–69
36. Flin R, Burns C, Mearns K, Yule S, Robertson EM. 2006. Measuring safety climate in health care. Qual.

Saf. Health Care 15(2):109–15
37. Fourcade A, Blache JL, Grenier C, Bourgain JL, Minvielle E. 2012. Barriers to staff adoption of a surgical

safety checklist. BMJ Qual. Saf. 21(3):191–97
38. Frankel A, Pratt Grillo S, Pittman M, Thomas EJ, Horowitz L, et al. 2008. Revealing and resolving

patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient
safety. Health Serv. Res. 43(6):2050–66

39. Furman C, Caplan R. 2007. Applying the Toyota Production System: using a patient safety alert system
to reduce error. Jt. Comm. J. Qual. Patient Saf. 33(7):376–86

40. Gallagher TH, Studdert D, Levinson W. 2007. Disclosing harmful medical errors to patients. N. Engl.
J. Med. 356(26):2713–19

41. Gandhi TK, Graydon-Baker E, Barnes JN, Neppl C, Stapinski C, et al. 2003. Creating an integrated
patient safety team. Jt. Comm. J. Qual. Saf. 29(8):383–90

42. Gandhi TK, Zuccotti G, Lee TH. 2011. Incomplete care—on the trail of flaws in the system. N. Engl.
J. Med. 365(6):486–88

43. Gandhi T, Graydon-Baker E, Huber C, Whittemore A, Gustafson M. 2005. Closing the loop: follow-up
and feedback in a patient safety program. Jt. Comm. J. Qual. Patient Saf. 31(11):614–21

44. Garbutt J, Milligan PE, McNaughton C, Highstein G, Waterman BM, et al. 2008. Reducing medication
prescribing errors in a teaching hospital. Jt. Comm. J. Qual. Patient Saf. 34(9):528–36

45. Gawande A. 2009. The Checklist Manifesto: How to Get Things Right. New York: Metrop. Books
46. Ginsburg LR, Chuang Y-T, Norton PG, Berta W, Tregunno D, et al. 2009. Development of a measure

of patient safety event learning responses. Health Serv. Res. 44(6):2123–47
47. Ginsburg L, Norton PG, Casebeer A, Lewis S. 2005. An educational intervention to enhance nurse

leaders’ perceptions of patient safety culture. Health Serv. Res. 40(4):997–1020
48. Gittell J. 2003. The Southwest Airlines Way: Using the Power of Relationships to Achieve High Performance.

New York: McGraw-Hill
49. Gittell JH, Seidner R, Wimbush J. 2010. A relational model of how high-performance work systems

work. Organ. Sci. 21(2):490–506
50. Goodman PS, Ramanujam R, Carroll JS, Edmondson AC, Hofmann DA, Sutcliffe KM. 2011. Organi-

zational errors: directions for future research. Res. Organ. Behav. 31:151–76
51. Gosbee J. 2002. Human factors engineering and patient safety. Qual. Saf. Health Care 11(4):352–54
52. Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida AJ. 2010. Harmful medication errors

involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Jt. Comm. J. Qual. Patient Saf. 36(5):195–202

390 Singer · Vogus

PU34CH22-Singer ARI 13 February 2013 23:6

53. Hackman JR, Wageman R. 1995. Total quality management: empirical, conceptual, and practical issues.
Adm. Sci. Q. 40(2):309–42

54. Halbesleben JRB, Rathert C. 2008. The role of continuous quality improvement and psychological safety
in predicting work-arounds. Health Care Manag. Rev. 33(2):134–44

55. Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. 2010. Rework and workarounds in nurse
medication administration process: implications for work processes and patient safety. Health Care Manag.
Rev. 35(2):124–33

56. Hales B, Terblanche M, Fowler R, Sibbald W. 2007. Development of medical checklists for improved
quality of patient care. Int. J. Qual. Health Care 20:22–30

57. Hansen LO, Williams MV, Singer SJ. 2010. Perceptions of hospital safety climate and incidence of
readmission. Health Serv. Res. 42(2):596–616

58. Hartmann CW, Rosen AK, Meterko M, Shokeen P, Zhao S, et al. 2008. An overview of patient safety
climate in the VA. Health Serv. Res. 43(4):1263–84

59. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, et al. 2009. A surgical safety checklist to
reduce morbidity and mortality in a global population. N. Eng. J. Med. 360(5):491–99

60. Helmchen LA, Richards MR, McDonald TB. 2011. Successful remediation of patient safety incidents:
a tale of two medication errors. Health Care Manag. Rev. 36(2):114–23

61. Henriksen K, Dayton E. 2006. Organizational silence and hidden threats to patient safety. Health Serv.
Res. 41(4p2):1539–54

62. Hibbard JH, Peters E, Slovic P, Tusler M. 2005. Can patients be part of the solution? Views on their
role in preventing medical errors. Med. Care Res. Rev. 62(5):601–16

63. Hofmann DA, Mark B. 2006. An investigation of the relationship between safety climate and medication
errors as well as other nurse and patient outcomes. Pers. Psychol. 59(4):847–69

64. Kalisch BJ, Curley M, Stefanov S. 2007. An intervention to enhance nursing staff teamwork and engage-
ment. J. Nurs. Adm. 37(2):77–84

65. Karnon J, McIntosh A, Dean J, Bath P, Hutchinson A, et al. 2007. A prospective hazard and improvement
analytic approach to predicting the effectiveness of medication error interventions. Saf. Sci. 45(4):523–39

66. Katz-Navon T, Naveh E, Stern Z. 2005. Safety climate in healthcare organizations: a multidimensional
approach. Acad. Manag. J. 48(6):1075–89

67. Kaushal R, Shojania KG, Bates DW. 2003. Effects of computerized physician order entry and clinical
decision support systems on medication safety: a systematic review. Arch. Intern. Med. 163(12):1409–16

68. Kemper PF, de Bruijne M, van Dyck C, Wagner C. 2011. Effectiveness of classroom based crew resource
management training in the intensive care unit: study design of a controlled trial. BMC Health Serv. Res.
11(1):304

69. Kenney C. 2011. Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient
Experience. New York: Productivity

70. Kirch DG, Boysen PG. 2010. Changing the culture in medical education to teach patient safety. Health
Aff. 29(9):1600–4

71. Klein KJ, Ziegert JC, Knight AP, Xiao Y. 2006. Dynamic delegation: shared, hierarchical, and deindi-
vidualized leadership in extreme action teams. Adm. Sci. Q. 51(4):590–621

72. Knox G, Simpson K, Garite T. 1999. High reliability perinatal units: an approach to the prevention of
patient injury and medical malpractice claims. J. Healthc. Risk Manag. 19(2):24–32

73. Ko H, Turner T, Finnigan M. 2011. Systematic review of safety checklists for use by medical care teams
in acute hospital settings—limited evidence of effectiveness. BMC Health Serv. Res. 11(1):211

74. Kohn LT, Corrigan J, Donaldson MS, eds. 2000. To Err Is Human: Building a Safer Health System.
Washington, DC: Inst. Med./Natl. Acad. Press

75. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, et al. 2005. Role of computerized physician
order entry systems in facilitating medication errors. JAMA 293(10):1197–203

76. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. 2007. Deficits in commu-
nication and information transfer between hospital-based and primary care physicians: implications for
patient safety and continuity of care. JAMA 297(8):831–41

77. Kuperman GJ, Bobb A, Payne TH, Avery AJ, Gandhi TK, et al. 2007. Medication-related clinical decision
support in computerized provider order entry systems: a review. J. Am Med. Inform. Assoc. 14(1):29–40

www.annualreviews.org • Reducing Hospital Errors 391

PU34CH22-Singer ARI 13 February 2013 23:6

78. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. 2010. Temporal trends
in rates of patient harm resulting from medical care. N. Engl. J. Med. 363(22):2124–34

79. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, et al. 2004. Effect of reducing interns’
work hours on serious medical errors in intensive care units. N. Engl. J. Med. 351(18):1838–48

80. Levtzion-Korach O, Frankel A, Alcalai H, Keohane C, Orav J, et al. 2010. Integrating incident data from
five reporting systems to assess patient safety: making sense of the elephant. Jt. Comm. J. Qual. Patient
Saf. 36(9):402–10

81. Lindquist LA, Gleason KM, McDaniel MR, Doeksen A, Liss D. 2008. Teaching medication reconcilia-
tion through simulation: a patient safety initiative for second year medical students. J. Gen. Intern. Med.
23(7):998–1001

82. Litvak E, Buerhaus PI, Davidoff F, Long MC, McManus ML, Berwick DM. 2005. Managing unnecessary
variability in patient demand to reduce nursing stress and improve patient safety. Jt. Comm. J. Qual. Patient
Saf. 31(6):330–38

83. Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, et al. 2007. Effects of health care
provider work hours and sleep deprivation on safety and performance. Jt. Comm. J. Qual. Patient Saf.
33(11 Suppl.):7–18

84. Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, et al. 2004. Effect of reducing interns’ weekly
work hours on sleep and attentional failures. N. Engl. J. Med. 351(18):1829–37

85. Logan CA, Cressey BD, Wu RY, Janicki AJ, Chen CX, et al. 2012. Monitoring universal protocol compli-
ance through real-time clandestine observation by medical students results in performance improvement.
J. Surg. Educ. 69(1):41–46

86. Macrae C. 2008. Learning from patient safety incidents: creating participative risk regulation in health-
care. Health Risk Soc. 10(1):53–67

87. Madsen P, Desai V, Roberts K, Wong D. 2006. Mitigating hazards through continuing design: the birth
and evolution of a pediatric intensive care unit. Organ. Sci. 17(2):239–48

88. Manojlovich M. 2010. Nurse/physician communication through a sensemaking lens: shifting the
paradigm to improve patient safety. Med. Care 48(11):941–46

89. Mawji Z, Stillman P, Laskowski R, Lawrence S, Karoly E, et al. 2002. First do no harm: integrating
patient safety and quality improvement. Jt. Comm. J. Qual. Improv. 28(7):373–86

90. McCannon CJ, Schall MW, Calkins DR, Nazem AG. 2006. Saving 100,000 lives in US hospitals. BMJ
332(7553):1328–30

91. McDonald KM, Romano PS, Geppert JJ, Davies SM, Duncan B, et al. 2002. Measures of Patient
Safety Based on Hospital Administrative Data: The Patient Safety Indicators. Tech. Rev. No. 5 (Pre-
pared by the Univ. Calif. San Franc.—Stanford Evidence-Based Cent., Contract no. 290-97-0013).
Rockville, MD: Agency for Healthc. Res. Quality (AHRQ), Publ. No. 02-0038. http://www.ncbi.nlm.
nih.gov/books/NBK43854/pdf/TOC

92. McFadden KL, Henagan SC, Gowen CR. 2009. The patient safety chain: transformational leadership’s
effect on patient safety culture, initiatives, and outcomes. J. Oper. Manag. 27(5):390–404

93. Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. 2010. Mixed results in the safety performance
of computerized physician order entry. Health Aff. 29(4):655–63

94. Moss J. 2010. Reducing errors during patient-controlled analgesia therapy through failure mode and
effects analysis. Jt. Comm. J. Qual. Patient Saf. 36(8):359–64

95. Moulton C-A, Regehr G, Lingard L, Merritt C, Macrae H. 2010. Operating from the other side of the
table: control dynamics and the surgeon educator. J. Am. Coll. Surg. 210(1):79–86

96. Mullen JE, Kelloway EK. 2010. Safety leadership: a longitudinal study of the effects of transformational
leadership on safety outcomes. J. Occup. Organ. Psychol. 82(2):253–72

97. Nagpal K, Vats A, Lamb B, Ashrafian H, Sevdalis N, et al. 2010. Information transfer and communication
in surgery: a systematic review. Ann. Surg. 252(2):225–39

98. Narimasu J, Dragnich A, Mulroy MF. 2010. Simply introducing a pre-operative checklist does not
produce teamwork behavior. Proc. 2010 Annu. Meet. Am. Soc. Anesthesiol. Oct. 16–20, San Diego, CA,
p. A382

99. Naveh E, Katz-Navon T, Stern Z. 2006. Readiness to report medical treatment errors: the effects of
safety procedures, safety information, and priority of safety. Med. Care 44(2):117–23

392 Singer · Vogus

http://www.ncbi.nlm.nih.gov/books/NBK43854/pdf/TOC

PU34CH22-Singer ARI 13 February 2013 23:6

100. Naveh E, Katz-Navon T, Stern Z. 2005. Treatment errors in healthcare: a safety climate approach.
Manag. Sci. 51(6):948–60

101. Neal A, Griffin M. 2006. A study of the lagged relationships among safety climate, safety motivation,
safety behavior, and accidents at the individual and group levels. J. Appl. Psychol. 91(4):946–53

102. Needleman JJ, Buerhaus PIP, Stewart MM, Zelevinsky KK, Mattke SS. 2006. Nurse staffing in hospitals:
Is there a business case for quality? Health Aff. 25(1):204–11

103. Nembhard IM. 2009. Learning and improving in quality improvement collaboratives: Which collabo-
rative features do participants value most? Health Serv. Res. 44(2 Part 1):359–78

104. Nembhard IM. 2012. All teach, all learn, all improve? The role of interorganizational learning in quality
improvement collaboratives. Health Care Manag. Rev. 37(2):154–64

105. Nembhard IM, Edmondson AC. 2006. Making it safe: the effects of leader inclusiveness and professional
status on psychological safety and improvement efforts in health care teams. J. Organ. Behav. 27(7):941–66

106. Ngo-Metzger Q, Hayes GR, Yunan Chen, Cygan R, Garfield CF. 2010. Improving communication
between patients and providers using health information technology and other quality improvement
strategies: focus on low-income children. Med. Care Res. Rev. 67(5 Suppl.):S246–67

107. Nieva V, Sorra J. 2003. Safety culture assessment: a tool for improving patient safety in healthcare
organizations. Qual. Saf. Health Care 12(Suppl. II):ii17–23

108. Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. 2007. Rates and types of events reported to
established incident reporting systems in two US hospitals. Qual. Saf. Health Care 16(3):164–68

109. Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. 2010. A novel method for reproducibly measuring
the effects of interventions to improve emotional climate, indices of team skills and communication, and
threat to patient outcome in a high-volume thoracic surgery center. Arch. Surg. 145(5):489–95

110. O’Leary KJ, Wayne DB, Haviley C, Slade ME, Lee J, Williams MV. 2010. Improving teamwork: impact
of structured interdisciplinary rounds on a medical teaching unit. J. Gen. Intern. Med. 25(8):826–32

111. Orlander JDJ, Barber TWT, Fincke BGB. 2002. The morbidity and mortality conference: the delicate
nature of learning from error. Acad. Med. 77(10):1001–6

112. Orlander JDJ, Fincke BGB. 2003. Morbidity and mortality conference: a survey of academic internal
medicine departments. J. Gen. Intern. Med. 18(8):656–58

113. Parente ST, McCullough JS. 2009. Health information technology and patient safety: evidence from
panel data. Health Aff. 28(2):357–60

114. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. 2003. Discussion of medical errors in morbidity
and mortality conferences. JAMA 290(21):2838–42

115. Piotrowski M, Saint S, Hinshaw D. 2002. The safety case management committee: expanding the avenues
for addressing patient safety. Jt. Comm. J. Qual. Improv. 28(6):296–305

116. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, et al. 2010. Effect of bar-code technology on
the safety of medication administration. N. Engl. J. Med. 362(18):1698–707

117. Preuss G. 2003. High performance work systems and organizational outcomes: the mediating role of
information quality. Ind. Labor Relat. Rev. 56:590–605

118. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, et al. 2006. Creating high
reliability in health care organizations. Health Serv. Res. 41(4 Part 2):1599–617

119. Pronovost PJ, Goeschel CA, Olsen KL, Pham JC, Miller MR, et al. 2009. Reducing health care hazards:
lessons from the commercial aviation safety team. Health Aff. 28(3):w479–89

120. Pronovost P, Vohr E. 2010. Safe Patients, Smart Hospitals. New York: Hudson Str.
121. Pronovost P, Weast B, Rosenstein B, Sexton JB, Holzmueller CG, et al. 2005. Implementing and vali-

dating a comprehensive unit-based safety program. J. Patient Saf. 1(1):33–40
122. Pronovost P, Weast B, Bishop K, Paine L, Griffith R, et al. 2004. Senior executive adopt-a-work unit: a

model for safety improvement. Jt. Comm. J. Qual. Saf. 30(2):59–68
123. Ramanujam R, Rousseau DM. 2006. The challenges are organizational not just clinical. J. Organ. Behav.

27(7):811–27
124. Reason J. 1997. Managing the risks of organizational accidents. Aldershot, Engl.: Ashgate
125. Reason J. 2004. Beyond the organisational accident: the need for “error wisdom” on the frontline. Qual.

Saf. Health Care 13(Suppl. 2):ii28–33

www.annualreviews.org • Reducing Hospital Errors 393

PU34CH22-Singer ARI 13 February 2013 23:6

126. Rosen AK, Loveland SA, Romano PS, Itani KMF, Silber JH, et al. 2009. Effects of resident duty hour
reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Admin-
istration and Medicare patients. Med. Care 47(7):723–31

127. Rosen AK, Singer S, Zhao S, Shokeen P, Meterko M, Gaba D. 2010. Hospital safety climate and safety
outcomes: Is there a relationship in the VA? Med. Care Res. Rev. 67(5):590–608

128. Rubin G, George A, Chinn DJ, Richardson C. 2003. Errors in general practice: development of an error
classification and pilot study of a method for detecting errors. Qual. Saf. Health Care 12(6):443–47

129. Schaefer H, Helmreich RL, Scheideggar D. 1994. Human factors and safety in emergency medicine.
Resuscitation 28:221–25

130. Schein EH. 1992. Organizational Culture and Leadership. San Francisco: Jossey-Bass
131. Schwappach DLB. 2010. Engaging patients as vigilant partners in safety: a systematic review. Med. Care

Res. Rev. 67(2):119–48
132. Seago JA, Williamson A, Atwood C. 2006. Longitudinal analyses of nurse staffing and patient outcomes:

more about failure to rescue. J. Nurs. Adm. 36(1):13–21
133. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. 2001. Making health care

safer: summary.In AHRQ Evidence Report Summaries. Rockville, MD: Agency Healthc. Res. Qual. US.
http://www.ncbi.nlm.nih.gov/books/NBK11945/

134. Shortell SM, Singer SJ. 2008. Improving patient safety by taking systems seriously. JAMA 299(4):445–47
135. Shortell SM, Zimmerman JE, Rousseau DM, Gillies RR, Wagner DP, et al. 1994. The performance of

intensive care units: Does good management make a difference? Med. Care 32(5):508–25
136. Simpson KR, Knox GE, Martin M, George C, Watson SR. 2011. Michigan Health & Hospital Associ-

ation Keystone Obstetrics: a statewide collaborative for perinatal patient safety in Michigan. Jt. Comm.
J. Qual. Patient Saf. 37(12):544–52

137. Singer SJ, Falwell A, Gaba DM, Baker LC. 2008. Patient safety climate in US hospitals: variation by
management level. Med. Care 46(11):1149–56

138. Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. 2009. Patient safety climate in 92 US hospitals:
differences by work area and discipline. Med. Care 47(1):23–31

139. Singer SJ, Moore SC, Meterko M, Williams S. 2012. Development of a short-form learning organization
survey: the LOS-27. Med. Care Res. Rev. 69(4):432–59

140. Singer SJ, Hayes J, Cooper JB, Vogt JW, Sales M, et al. 2011. A case for safety leadership team training
of hospital managers. Health Care Manag. Rev. 36(2):1–13

141. Singer S, Lin S, Falwell A, Gaba D, Baker L. 2009. Relationship of safety climate and safety performance
in hospitals. Health Serv. Res. 44(2 Part 1):399–421

142. Singh H, Naik AD, Rao R, Petersen LA. 2008. Reducing diagnostic errors through effective communi-
cation: harnessing the power of information technology. J. Gen. Intern. Med. 23(4):489–94

143. Sirio CA, Segel KT, Keyser DJ, Harrison EI, Lloyd JC, et al. 2003. Pittsburgh Regional Healthcare
Initiative: a systems approach for achieving perfect patient care. Health Aff. 22(5):157–65

144. Sitkin SB. 1992. Learning through failure: the strategy of small losses. Res. Organ. Behav. 14:231–66
145. Sittig DF, Classen DC. 2010. Safe electronic health record use requires a comprehensive monitoring

and evaluation framework. JAMA 303(5):450–51
146. Solberg LI, Asche SE, Averbeck BM, Hayek AM, Schmitt KG, et al. 2008. Can patient safety be measured

by surveys of patient experiences? Jt. Comm. J. Qual. Patient Saf. 34(5):266–74
147. Stablein D, Welebob E, Johnson E, Metzger J, Burgess R, Classen DC. 2003. Understanding hospital

readiness for computerized physician order entry. Jt. Comm. J. Qual. Saf. 29(7):336–44
148. Stern Z, Katz-Navon T, Naveh E. 2008. The influence of situational learning orientation, autonomy,

and voice on error making: the case of resident physicians. Manag. Sci. 54(9):1553–64
149. Sujan M-A, Ingram C, McConkey T, Cross S, Cooke MW. 2011. Hassle in the dispensary: pilot study

of a proactive risk monitoring tool for organisational learning based on narratives and staff perceptions.
BMJ Qual. Saf. 20(6):549–56

150. Suresh G, Horbar J, Plsek P, Gray J, Edwards W, et al. 2004. Voluntary anonymous reporting of medical
errors for neonatal intensive care. Pediatrics 113(6):1609–18

151. Sutcliffe KM, Lewton E, Rosenthal MM. 2004. Communication failures: an insidious contributor to
medical mishaps. Acad. Med. 79(2):186–94

394 Singer · Vogus

http://www.ncbi.nlm.nih.gov/books/NBK11945/

PU34CH22-Singer ARI 13 February 2013 23:6

152. Szekendi MK, Barnard C, Creamer J, Noskin GA. 2010. Using patient safety morbidity and mortality
conferences to promote transparency and a culture of safety. Jt. Comm. J. Qual. Patient Saf. 36(1):3–9

153. Tamuz M, Franchois KE, Thomas EJ. 2011. What’s past is prologue: organizational learning from a
serious patient injury. Saf. Sci. 49(1):75–82

154. Toussaint J, Gerard R, Adams E. 2010. On the Mend: Revolutionizing Healthcare to Save Lives and Transform
the Industry. Cambridge, MA: Lean Enterp. Inst.

155. Tucker A. 2007. An empirical study of system improvement by frontline employees in hospital units.
Manuf. Serv. Oper. Manag. 9(4):492–505

156. Tucker AL. 2004. The impact of operational failures on hospital nurses and their patients. J. Oper.
Manag. 22(2):151–67

157. Tucker AL, Edmondson AC. 2003. Why hospitals don’t learn from failures: organizational and psycho-
logical dynamics that inhibit system change. Calif. Manag. Rev. 45(2):55–72

158. Tucker AL, Nembhard IM, Edmondson A. 2007. Implementing new practices: an empirical study of
organizational learning in hospital intensive care units. Manag. Sci. 53(6):894–907

159. Tucker AL, Singer SJ, Hayes JE, Falwell A. 2008. Front-line staff perspectives on opportunities for
improving the safety and efficiency of hospital work systems. Health Serv. Res. 43(5 Part 2):1807–29

160. Valentine MA, Nembhard IM, Edmondson AC. 2011. Measuring teamwork in health care settings: a review
of survey instruments. Work. Pap. No. 11-116, Technol. Oper. Manag., Harvard Bus. School

161. Vashdi DR, Bamberger PA, Erez M, Weiss-Meilik A. 2007. Briefing-debriefing: using a reflexive orga-
nizational learning model from the military to enhance the performance of surgical teams. Hum. Resour.
Manag. 46(1):115–42

162. Vogus TJ, Sutcliffe KM. 2007. The safety organizing scale: development and validation of a behavioral
measure of safety culture in hospital nursing units. Med. Care 45(1):46–54

163. Vogus TJ, Sutcliffe KM. 2007. The impact of safety organizing, trusted leadership, and care pathways
on reported medication errors in hospital nursing units. Med. Care 45(10):997–1002

164. Vogus TJ, Sutcliffe KM, Weick KE. 2010. Doing no harm: enabling, enacting, and elaborating a culture
of safety in health care. Acad. Manag. Perspect. 24(4):60–77

165. Wachter RM, Shojania KG. 2004. The faces of errors: a case-based approach to educating providers,
policymakers, and the public about patient safety. Jt. Comm. J. Qual. Saf. 30(12):665–70

166. Weaver SJ, Rosen MA, DiazGranados D, Lazzara EH, Lyons R, et al. 2010. Does teamwork improve
performance in the operating room? A multilevel evaluation. Jt. Comm. J. Qual. Patient Saf. 36(3):133–42

167. Weick KE, Sutcliffe KM. 2001. Managing the Unexpected: Assuring High Performance in an Age of Com-
plexity. San Francisco, CA: Jossey-Bass

168. Weick KE, Sutcliffe KM. 2003. Hospitals as cultures of entrapment: a re-analysis of the Bristol Royal
Infirmary. Calif. Manag. Rev. 45(2):73–84

169. Weiner B, Alexander J, Baker L, Shortell S, Becker M. 2006. Quality improvement implementation and
hospital performance on patient safety indicators. Med. Care Res. Rev. 63(1):29–57

170. Weingart SN, Morway L, Brouillard D, Cleary A, Eng TK, et al. 2009. Rating recommendations for
consumers about patient safety: sense, common sense, or nonsense? Jt. Comm. J. Qual. Patient Saf.
35:206–15

171. West AN, Weeks WB, Bagian JP. 2008. Rare adverse medical events in VA inpatient care: reliability
limits to using patient safety indicators as performance measures. Health Serv. Res. 43(1 Part 1):249–66

172. West MA, Guthrie JP, Dawson JF, Borrill CS, Carter M. 2006. Reducing patient mortality in hospitals:
the role of human resource management. J. Organ. Behav. 27(7):983–1002

173. Williams ES, Well LBM, Konrad TR, Linzer M. 2007. The relationship of organizational culture,
stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from
the MEMO study. Health Care Manag. Rev. 32(3):203–12

174. Wolf FA, Way LW, Stewart L. 2010. The efficacy of medical team training: improved team performance
and decreased operating room delays: a detailed analysis of 4863 cases. Ann. Surg. 252(3):477–83

175. Wolfstadt JI, Gurwitz JH, Field TS, Lee M, Kalkar S, et al. 2008. The effect of computerized physician
order entry with clinical decision support on the rates of adverse drug events: a systematic review. J. Gen.
Intern. Med. 23(4):451–58

www.annualreviews.org • Reducing Hospital Errors 395

PU34CH22-Singer ARI 13 February 2013 23:6

176. Woodward HI, Mytton OT, Lemer C, Yardley IE, Ellis BM, et al. 2010. What have we learned about
interventions to reduce medical errors? Annu. Rev. Public Health 31:479–97

177. Young GJ, Charns MP, Desai K, Khuri SF, Forbes MG, et al. 1998. Patterns of coordination and clinical
outcomes: a study of surgical services. Health Serv. Res. 33(5):1211–36

178. Young J, Wachter R. 2009. Applying Toyota Production System principles to a psychiatric hospital:
making transfers safer and more timely. Jt. Comm. J. Qual. Patient Saf. 35(9):439–48

179. Yun S, Faraj S, Sims HPJ. 2005. Contingent leadership and effectiveness of trauma resuscitation teams.
J. Appl. Psychol. 90(6):1288–96

180. Zhu J, Stuver SO, Epstein AM, Schneider EC, Weissman JS, Weingart SN. 2011. Can we rely on
patients’ reports of adverse events? Med. Care 49(10):948–55

181. Zohar D. 1980. Safety climate in industrial organizations: theoretical and applied implications. J. Appl.
Psychol. 65(1):96–102

182. Zohar D. 2002. The effects of leadership dimensions, safety climate, and assigned priorities on minor
injuries in work groups. J. Organ. Behav. 23(1):75–92

183. Zohar D. 2008. Safety climate and beyond: a multi-level multi-climate framework. Saf. Sci. 46(3):376–87
184. Zohar D, Luria G. 2003. The use of supervisory practices as leverage to improve safety behaviour: a

cross-level intervention model. J. Saf. Res. 34(5):567–77

396 Singer · Vogus

PU34-FrontMatter ARI 19 February 2013 13:11

Annual Review of
Public Health

Volume 34, 2013 Contents

Symposium: Developmental Origins of Adult Disease

From Developmental Origins of Adult Disease to Life Course Research
on Adult Disease and Aging: Insights from Birth Cohort Studies
Chris Power, Diana Kuh, and Susan Morton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

Routine Versus Catastrophic Influences on the Developing Child
Candice L. Odgers and Sara R. Jaffee � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �29

Intergenerational Health Responses to Adverse and
Enriched Environments
Lars Olov Bygren � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �49

Epidemiology and Biostatistics

Causal Inference in Public Health
Thomas A. Glass, Steven N. Goodman, Miguel A. Hernán,

and Jonathan M. Samet � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �61

Current Evidence on Healthy Eating
Walter C. Willett and Meir J. Stampfer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �77

Current Perspective on the Global and United States Cancer Burden
Attributable to Lifestyle and Environmental Risk Factors
David Schottenfeld, Jennifer L. Beebe-Dimmer, Patricia A. Buffler,

and Gilbert S. Omenn � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �97

viii

PU34-FrontMatter ARI 19 February 2013 13:11

The Epidemiology of Depression Across Cultures
Ronald C. Kessler and Evelyn J. Bromet � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 119

Routine Versus Catastrophic Influences on the Developing Child
Candice L. Odgers and Sara R. Jaffee � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �29
Intergenerational Health Responses to Adverse and
Enriched Environments
Lars Olov Bygren � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �49

Environmental and Occupational Health

Causal Inference Considerations for Endocrine Disruptor Research in
Children’s Health
Stephanie M. Engel and Mary S. Wolff � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 139

Energy and Human Health
Kirk R. Smith, Howard Frumkin, Kalpana Balakrishnan, Colin D. Butler,

Zoë A. Chafe, Ian Fairlie, Patrick Kinney, Tord Kjellstrom, Denise L. Mauzerall,
Thomas E. McKone, Anthony J. McMichael, and Mycle Schneider � � � � � � � � � � � � � � � � � � � 159

Links Among Human Health, Animal Health, and Ecosystem Health
Peter Rabinowitz and Lisa Conti � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 189

The Worldwide Pandemic of Asbestos-Related Diseases
Leslie Stayner, Laura S. Welch, and Richard Lemen � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 205

Transportation and Public Health
Todd Litman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 217

Public Health Practice

Implementation Science and Its Application to Population Health
Rebecca Lobb and Graham A. Colditz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 235

Promoting Healthy Outcomes Among Youth with Multiple Risks:
Innovative Approaches
Mark T. Greenberg and Melissa A. Lippold � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 253

Prospects for Tuberculosis Elimination
Christopher Dye, Philippe Glaziou, Katherine Floyd, and Mario Raviglione � � � � � � � � � � � 271

Rediscovering the Core of Public Health
Steven M. Teutsch and Jonathan E. Fielding � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 287

Contents ix

PU34-FrontMatter ARI 19 February 2013 13:11

Social Environment and Behavior

HIV Prevention Among Women in Low- and Middle-Income
Countries: Intervening Upon Contexts of Heightened HIV Risk
Steffanie A. Strathdee, Wendee M. Wechsberg, Deanna L. Kerrigan,

and Thomas L. Patterson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 301

Scaling Up Chronic Disease Prevention Interventions in Lower- and
Middle-Income Countries
Thomas A. Gaziano and Neha Pagidipati � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 317

Stress and Cardiovascular Disease: An Update on Current Knowledge
Andrew Steptoe and Mika Kivimäki � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 337

The Impact of Labor Policies on the Health of Young Children in the
Context of Economic Globalization
Jody Heymann, Alison Earle, and Kristen McNeill � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 355

Commentary on the Symposium: Biological Embedding, Life Course
Development, and the Emergence of a New Science
Clyde Hertzman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1
From Developmental Origins of Adult Disease to Life Course Research
on Adult Disease and Aging: Insights from Birth Cohort Studies
Chris Power, Diana Kuh, and Susan Morton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7
Intergenerational Health Responses to Adverse and
Enriched Environments
Lars Olov Bygren � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �49
Promoting Healthy Outcomes Among Youth with Multiple Risks:
Innovative Approaches
Mark T. Greenberg and Melissa A. Lippold � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 253

The Behavioral Economics of Health and Health Care
Thomas Rice � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 431

Health Services

Reducing Hospital Errors: Interventions that Build Safety Culture
Sara J. Singer and Timothy J. Vogus � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 373

Searching for a Balance of Responsibilities: OECD Countries’
Changing Elderly Assistance Policies
Katherine Swartz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 397

x Contents

PU34-FrontMatter ARI 19 February 2013 13:11

Strategies and Resources to Address Colorectal Cancer Screening
Rates and Disparities in the United States and Globally
Michael B. Potter � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 413

The Behavioral Economics of Health and Health Care
Thomas Rice � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 431
Scaling Up Chronic Disease Prevention Interventions in Lower- and
Middle-Income Countries
Thomas A. Gaziano and Neha Pagidipati � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 317

Indexes

Cumulative Index of Contributing Authors, Volumes 25–34 � � � � � � � � � � � � � � � � � � � � � � � � � � � 449

Cumulative Index of Article Titles, Volumes 25–34 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 454

Errata

An online log of corrections to Annual Review of Public Health articles may be found at
http://publhealth.annualreviews.org/

Contents xi

Annual Reviews Online
Search Annual Reviews
Annual Review of Public Health
Online

Most Downloaded Public Health
Reviews
Most Cited Public Health
Reviews
Annual Review of Public Health
Errata
View Current Editorial Committee

All Articles in the Annual Review of Public Health, Vol. 34

Symposium: Developmental Origins of Adult Disease
Commentary on the Symposium: Biological Embedding, Life Course Development, and the Emergence of a New Science
From Developmental Origins of Adult Disease to Life Course Researchon Adult Disease and Aging: Insights from Birth Cohort Studies
Routine Versus Catastrophic Influences on the Developing Child
Intergenerational Health Responses to Adverse and Enriched Environments
Epidemiology and Biostatistics
Commentary on the Symposium: Biological Embedding, Life Course Development, and the Emergence of a New Science
From Developmental Origins of Adult Disease to Life Course Researchon Adult Disease and Aging: Insights from Birth Cohort Studies
Causal Inference in Public Health
Current Evidence on Healthy Eating
Current Perspective on the Global and United States Cancer Burden Attributable to Lifestyle and Environmental Risk Factors
The Epidemiology of Depression Across Cultures
Intergenerational Health Responses to Adverse and Enriched Environments
Environmental and Occupational Health
Intergenerational Health Responses to Adverse and Enriched Environments
Causal Inference Considerations for Endocrine Disruptor Research in Children’s Health
Energy and Human Health
Links Among Human Health, Animal Health, and Ecosystem Health
The Worldwide Pandemic of Asbestos-Related Diseases
Transportation and Public Health
Public Health Practice
Implementation Science and Its Application to Population Health
Promoting Healthy Outcomes Among Youth with Multiple Risks:Innovative Approaches
Prospects for Tuberculosis Elimination
Rediscovering the Core of Public Health
Social Environment and Behavior
Routine Versus Catastrophic Influences on the Developing Child
HIV Prevention Among Women in Low- and Middle-Income Countries: Intervening Upon Contexts of Heightened HIV Risk
Scaling Up Chronic Disease Prevention Interventions in Lower- andMiddle-Income Countries
Stress and Cardiovascular Disease: An Update on Current Knowledge
The Impact of Labor Policies on the Health of Young Children in the Context of Economic Globalization
Commentary on the Symposium: Biological Embedding, Life CourseDevelopment, and the Emergence of a New Science
From Developmental Origins of Adult Disease to Life Course Researchon Adult Disease and Aging: Insights from Birth Cohort Studies
Intergenerational Health Responses to Adverse and Enriched Environments
Promoting Healthy Outcomes Among Youth with Multiple Risks:Innovative Approaches
The Behavioral Economics of Health and Health Care
Health Services
Reducing Hospital Errors: Interventions that Build Safety Culture
Searching for a Balance of Responsibilities: OECD Countries’ Changing Elderly Assistance Policies
Strategies and Resources to Address Colorectal Cancer Screening Rates and Disparities in the United States and Globally
The Behavioral Economics of Health and Health Care
Scaling Up Chronic Disease Prevention Interventions in Lower- and Middle-Income Countries

logo:

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

Order Now Talk to Us

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

Most Qualified Writer $10FREE
Plagiarism Scan Report $10FREE
Unlimited Revisions $08FREE
Paper Formatting $05FREE
Cover Page $05FREE
Referencing & Bibliography $10FREE
Dedicated User Area $08FREE
24/7 Order Tracking $05FREE
Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

On-time Delivery
24/7 Order Tracking
Access to Authentic Sources

Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

Call Us +1 (877) 657-8180 Discuss Order Details Now

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

Clear elicitation of your requirements.
Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

Proactive analysis of your writing.
Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

Thorough research and analysis for every order.
Deliverance of reliable writing service to improve your grades.

Place an Order Start Chat Now

Kim Woods

What Will You Get?

Premium Quality

Experienced Writers

On-Time Delivery

24/7 Customer Support

Complete Confidentiality

Authentic Sources

Moneyback Guarantee

Order Tracking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

Preferred Writer

Grammar Check Report

One Page Summary

Plagiarism Report

Free Features $66FREE

Our Services

Academic Writing

Professional Editing

Thorough Proofreading

Thorough Proofreading

Delegate Your Challenging Writing Tasks to Experienced Professionals

Check Out Our Sample Work

It May Not Be Much, but It’s Honest Work!

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

Share Your Requirements

Place Order & Deposit Funds

Release Payment to Your Writer

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We Mirror Your Guidelines to Deliver Quality Services

We Handle Your Writing Tasks to Ensure Excellent Grades