NOTES

1. L.L. Leape et al., “The Nature of Adverse Events
in Hospitalized Patients: Results from the Harvard Medical Practice Study II,” New England Journal of Medicine 324, no. 6 (1991): 377–384.

2. D.B. Prior, “Case Study: TheClinical Transformation of Ascension Health” (Presented at the Agency for Healthcare Research and Quality and
Institute for Healthcare Improvement Symposium
on Large Scale Change in the Quality of American Health Care: Key Challenges and Lessons
Learned about Spreading and Sustaining National Improvement, Rockville, Maryland, 16 March 2007).

3. P. Pronovost et al., “An Intervention to Decrease
Catheter-Related Bloodstream Infections in the ICU,” New England Journal of Medicine 355, no. 26 (2006): 2725–2732.

4. Ibid.

5. S.S. Kraman and G. Hamm, “Risk Management: Extreme Honesty May Be the Best Policy,” Annals of Internal Medicine 131, no. 12 (1999): 963–967; R.E. Quinn, “The Insurance Industry’s Role in Supporting Apology and Disclosure Policies” (Presented at the Joint Commission Conference on Seeing Your Way Clear to Apology and Disclosure, Rosemont, Illinois, 6 June 2007); and S. Hall, “U-M Docs Say Sorry, Avert Suits,” Detroit News, 12 May 2004.

6. Massachusetts Coalition for the Prevention of Medical Errors, “When Things Go Wrong, a Consensus Statement of the Harvard Hospitals” (Boston: Massachusetts Coalition, 2006).

7. A. Rosenstein and M. O’Daniel, “Disruptive Behavior and Clinical Outcomes: Perceptions of Nurses and Physicians,” American Journal of Nursing 105, no. 1 (2005): 54–64.