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by Yaneer Bar-Yam
Step V: Improve communication

For Further Reading:

1. Y. Bar-Yam, Making things work. (NECSI Knowledge Press, Cambridge, MA, 2004). See chapter 11.

2. Y. Bar-Yam, System care: multiscale analysis of medical errors—eliminating errors and improving organizational capabilities, NECSI Technical Report (9/1/2004).

3. Y. Bar-Yam, M. Smith, A. Wachman, S. Topolski, Prescription form with redundancy, New England Complex Systems Institute.

4. A. Goldstein, Overdose kills girl at Children's Hospital, Washington Post (4/20/2001).

5. R. Shapiro, Preventable Medical Malpractice: Revisiting the Dennis Quaid Medication/Hospital Error Case, The Injury Board Blog Network (8/9/2010).

6. Experts to probe factors behind overdose error, Edmonton Journal (5/8/2007).

7. To err is human: building a safer health system, Institute of Medicine (The National Academies Press, Washington, DC, 2000).

8. Preventing medication errors: quality chasm series, Institute of Medicine (The National Academies Press, Washington, DC, 2007). [Press release: Medication errors injure 1.5 million people and cost billions of dollars annually; report offers comprehensive strategies for reducing drug-related mistakes. National Academies press release (7/20/2006).]

9. M. Graban, Statistics on healthcare quality and patient safety, Leanblog compilation (8/9/2009).

10. Drugs: Drug safety and availability: Medication errors, US Dept. of Health & Human Services, Food and Drug Administration.

11. FDA and ISMP launch campaign to reduce medication mistakes caused by unclear medical abbreviations, Food and Drug Administration press release (6/14/2006).

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