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Organisational culture and quality of health care. Quality in Health Care 9 2 � Dhaliwal, G. Blueprint for diagnostic excellence. Dixon-Woods, M. Bosk, E. Aveling, C.

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Focus on diagnostic errors: Understanding and prevention. Patient safety beyond the hospital. New England Journal of Medicine 11 � Neppl Huber, A. Whittemore, and M. Closing the loop: Follow-up and feedback in a patient safety program. Kachalia, E. Thomas, A. Puopolo, C.

Yoon, T. Brennan, and D. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims.

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Diagnostic error in internal medicine. Archives of Internal Medicine 13 � Kissam, V. Payne, A. Meyer, A. Sorensen, N. Lenfestey, E. Tant, K. Henriksen, K. LaBresh, and H. Cognitive interventions to reduce diagnostic error: A narrative review. Wachter, and C. Bringing diagnosis into the quality and safety equations. JAMA 12 � Trowbridge, J. Myers, C. Umscheid, W.

Strull, and M. The next organizational challenge: Finding and addressing diagnostic error. Grumbach, K. Lucey, and S. Transforming from centers of learning to learning health systems: The challenge for academic health centers.

JAMA 11 � Hall, P. Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care 19 Suppl 1 � What is workflow redesign? Why is it important? Improving diagnostic performance: Some unrecognized obstacles.

Diagnosis 1 1 � Organizational silence and hidden threats to patient safety. Health Services Research 41 4p2 � Test results reporting and follow-up.

Hill, R. The autopsy�Medical practice and public policy. Boston: Butterworths. Hines, S. Luna, J. Lofthus, M. Marquardt, and D. Becoming a high reliability organization: Operational advice for hospital leaders. Hoffman, J. Intolerance of error and culture of blame drive medical excess. BMJ g Hogarth, R. On the learning of intuition. Plessner, C. Betsch, and T. Betsch eds. Hysong, S. Best, and J.

Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implementation Science 1 9. Ilgen, D. Fisher, and M. Consequences of individual feedback on behavior in organizations. Journal of Applied Psychology 64 4 � IOM Institute of Medicine. To err is human: Building a safer health system. Patient safety: Achieving a new standard for care.

Resident duty hours: Enhancing sleep, supervision, and safety. A CEO checklist for high-value health care: Discussion paper. Best care at lower cost: The path to continuously learning health care in America.

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How Intermountain trimmed health care costs through robust quality improvement efforts. Health Affairs Millwood 30 6 � Jeffe, D. Dunagan, J. Garbutt, T. Burroughs, T. Gallagher, P. Hill, C. Harris, K. Bommarito, and V. Jimmerson, C. Weber, and D. Reducing waste and errors: Piloting lean principles at Intermountain Healthcare. Johnson, A. Cognitive facilitation following intentional odor exposure. Sensors 11 5 � The Joint Commission.

Leadership in healthcare organizations: A guide to joint commission leadership standards. Sentinel Event Policy and Procedures. Kachalia, A. Improving patient safety through transparency. Kanter, M. Diagnostic errors�Patient safety. Kelly, M.

Xie, P. Carayon, L. DuBenske, M. Ehlenbach, and E. Strategies for improving family engagement during family-centered rounds. Journal of Hospital Medicine 8 4 � Khatri, N. Brown, and L. From a blame culture to a just culture in health care. Health Care Management Review 34 4 � Khunlertkit, A. Contributions of tele-intensive care unit Tele-ICU technology to quality of care and patient safety.

Journal of Critical Care 28 3 Kirwan, B. Ainsworth eds. A guide to task analysis: The task analysis working group. Kotter, J. Leading change: Why transformation efforts fail. Harvard Business Review. January The key to changing organizational culture. Forbes , September Kroft, S. American Society for Clinical Pathology. Kruskal, J. Siewert, S. Anderson, R. Eisenberg, and J. Managing an acute adverse event in a radiology department.

RadioGraphics 28 5 � Lacson, R. Andriole, L. Prevedello, and R. Automated critical test result notification system: Architecture, design, and assessment of provider satisfaction. American Journal of Roentgenology 5 :W�W Prevedello, K. Andriole, S. Roy, T. Gandhi, A. Dalal, L. Sato, and R.

Four-year impact of an alert notification system on closed-loop communication of critical test results. American Journal of Roentgenololgy 5 � Larson, E. Academic Medicine 77 10 � Lavanya, T. Cohen, S. Farrell, and E. A case of a Dandy-Walker variant: The importance of a multidisciplinary team approach using complementary techniques to obtain accurate diagnostic information.

British Journal of Radiology 81 :e�e Lee, C. Nagy, S. Weaver, and D. Cognitive and system factors contributing to diagnostic errors in radiology. American Journal of Roentgenology 3 � Lopez-Campos, J. Asensio-Cruz, A. Castro-Acosta, C. Calero, and F. Lundberg, G. Low-tech autopsies in the era of high-tech medicine: Continued value for quality assurance and patient safety.

JAMA 14 � Marcovici, P. Structured radiology reports are more complete and more effective than unstructured reports. American Journal of Roentgenology 6 : � Marx, D. McDonald, K. Matesic, D. Contopoulos�Ioannidis, J. Lonhart, E. Schmidt, N. Pineda, and J.

Patient safety strategies targeted at diagnostic errors: A systematic review. Annals of Internal Medicine 5 Part 2 � Report to the Congress: Selected Medicare issues. Mehta, R. Zhu, and A. Is noise always bad? Exploring the effects of ambient noise on creative cognition. Journal of Consumer Research 39 4 � Milstead, J. The culture of safety. Modak, I. Sexton, T. Lux, R. Helmreich, and E. Journal of General Internal Medicine 22 1 :1�5. Moran, J. Leading organizational change.

Journal of Workplace Learning 12 2 � Murphy, D. Laxmisan, B. Reis, E. Esquivel, S. Forjuoh, R. Parikh, M. Khan, and H. Electronic health record-based triggers to detect potential delays in cancer diagnosis. Myers, J. Diagnostic errors in. Nakhleh, R. Nose, C. Colasacco, L. Fatheree, T. Lillemoe, D.

McCrory, F. Meier, C. Otis, S. Owens, S. Raab, R. Turner, C. Ventura, and A. Interpretive diagnostic error reduction in surgical pathology and cytology: Guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

Accountable care organization accreditation. Nemetz, P. Tangalos, L. Sands, W. Fisher Jr, W. Newman III, and E. Attitudes toward the autopsy�An 8-state survey. Medscape General Medicine 8 3 Newman-Toker, D. McDonald, and D. How much diagnostic safety can we afford, and how should we decide? A health economics perspective.

Serious reportable events in healthcare� update: A consensus report. Post-mortem radiology�A new sub-speciality?

Clinical Radiology 63 11 � Parmelli, E. Flodgren, F. Beyer, N. Baillie, M. Schaafsma, and M. The effectiveness of strategies to change organisational culture to improve healthcare performance: A systematic review.

Implementation Science 6 1 Parsons, K. Environmental ergonomics: A review of principles, methods and models. Applied Ergonomics 31 6 � Perlman, K. Change fatigue: Taking its toll on your employees? Pichereau, C. Maury, L. Monnier-Cholley, S. Bourcier, G. Lejour, M. Alves, J. Baudel, H. Ait Oufella, B. Guidet, and L. Post-mortem CT scan with contrast injection and chest compression to diagnose pulmonary embolism.

Intensive Care Medicine 41 1 � Plaza, C. Beard, A. Fonzo, M. Tommaso, Y. Mujawaz, M. Serra-Julia, and D. Innovation in healthcare team feedback. Healthcare Quarterly 14 2 � Plebani, M. Closing the brain-to-brain loop in laboratory testing. Clinical Chemistry and Laboratory Medicine 49 7 � Laposata, and G. The brain-to-brain loop concept for laboratory testing 40 years after its introduction. American Journal of Clinical Pathology 6 � Pronovost, P.

Berenholtz, C. Goeschel, D. Needham, J. Sexton, D. Thompson, L. Lubomski, J. Marsteller, M. Makary, and E. Creating high reliability in health care organizations.

Berenholtz, and D. Translating evidence into practice: a model for large scale knowledge translation. BMJ a Goeschel, E. Colantuoni, S. Watson, L. Lubomski, S. Berenholtz, D. Thompson, D. Sinopoli, S. Cosgrove, J. Sexton, J. Marsteller, R. Hyzy, R. Welsh, P.

Posa, K. Schumacher, and D. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ c Provenzale, J. Understanding errors in diagnostic radiology: Proposal of a classification scheme and application to emergency radiology. Emergency Radiology 18 5 � Reiling, J. Hughes, and M. Chapter The impact of facility design on patient safety.

Hughes ed. Reilly, J. Myers, D. Salvador, and R. Use of a novel, modified fishbone diagram to analyze diagnostic errors. Diagnosis 1 2 � Graber, and R. How to do a root cause analysis of diagnostic error. Roberts, I. Benamore, E. Benbow, S. Lee, J. Harris, A. Jackson, S.

Mallett, T. Patankar, C. Peebles, C. Roobottom, and Z. Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: A validation study. Lancet � Rogers, M. Patterson, and M. Cognitive work analysis in health care.

Carayon ed. Roth, E. Uncovering the requirements of cognitive work. Roy, C. Rothschild, A. Dighe, G. Schiff, E. Graydon-Baker, J. Lenoci-Edwards, C. Dwyer, R. Khorasani, and T. An initiative to improve the management of clinically significant test results in a large health care network. Ruegger, C. Bartsch, R. Martinez, S. Ross, S. Bolliger, B. Koller, L. Held, E. Bruder, P.

Bode, R. Caduff, B. Frey, L. Schaffer, and H. Minimally invasive, imaging guided virtual autopsy compared to conventional autopsy in foetal, newborn and infant cases: Study protocol for the paediatric virtual autopsy trial. BMC Pediatrics 14 1 Salas, E. Prince, D. Baker, and L. Situation awareness in team performance: Implications for measurement and training.

Saldiva, P. Minimally invasive autopsies: A promise to revive the procedure. Autopsy and Case Reports 4 3. Schein, E. Organizational culture and leadership , 3rd ed. Schiff, G. Commentary: Diagnosis tracking and health reform.

American Journal of Medical Quality 9 4 � Minimizing diagnostic error: The importance of follow-up and feedback. American Journal of Medicine 5 :S38�S Klass, J. Peterson, G.

Shah, and D. Linking laboratory and pharmacy: Opportunities for reducing errors and improving care. Archives of Internal Medicine 8 � Kim, R. Abrams, K. Cosby, A. Elstein, S. Hasler, N. Krosnjar, R. Odwanzy, M.

Wisniewsky, and R. Diagnosing diagnosis errors: Lessons from a multi-institutional collaborative project for the diagnostic error evaluation and research project investigators. Henrikson, J.

Puopolo, A. Huben-Kearney, W. Yu, C. Keohane, P. McDonough, B. Ellis, D. Bates, and M. Primary care closed claims experience of Massachusetts malpractice insurers. Schwartz, A. The value of direct observation and feedback on provider performance in diagnosis. Weiner, F. Weaver, R. Yudkowsky, G. Sharma, A. Binns-Calvey, B.

Preyss, and N. Uncharted territory: Measuring costs of diagnostic errors outside the medical record. Schwartz, L. Panicek, A. Berk, Y. Li, and H. Improving communication of diagnostic radiology findings through structured reporting. Helmreich, T. Neilands, K.

Rowan, K. Vella, J. Boyden, P. Roberts, and E. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. Materials continue to be added to these files. Although a majority of the files consist of between two to four pages, a few contain up to four linear inches of material. Use and Reproduction Policy Biographical files are unavailable for loan and must be consulted in the library.

With regard to non-copyrighted materials, the use of digital cameras without flash is encouraged. Photocopying is generally prohibited, though permission to photocopy a few pages may be granted by the Reference staff, contingent upon the physical state of the documents.

All photocopying of materials shall be done by the Reference staff, Renken Boats Models Korea or under their close supervision. Abbot, Edward William Abbot Jr. Abbott, Clark Tait Abbott, Robert Lewis Abbott, William George Abele, Mannert Lincoln Abercrombie, Laurence Allen Abercrombie, William Warner Abernethy, Elmer Paul Abhau, William Conrad Abplanalp, Kenneth Clair Abrahams, Noble Wayne Acker, Frank Clements Ackerman, Edward Ackiss, Ernest Lee Acuff, Jasper Terry Adair, Charles Adair, Crutchfield Adair, Jamie Adam, James Davidson Adams, Allen Bond, Jr.

Adams, Benjamin Harrison Adams, Carlton Rolla Adams, Dudley Hale Adams, Frank Eugene Adams, John Clausel Adams, Lenus Franklin Adams, Lynn W. Adams, Richard Donald Adams, Robert Lee Adams, Scarritt Adams, Spencer Moore Adams, Thomas McConnell Adams, Woodbury Sanderson Adamson, Frank Marshall Adamson, Robert Edward, Jr.

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Aldridge, Eugene Talbert Alexander, Joe Mcknitt Alexander, John Richmond Alexander, Marion Snow Alexander, Ralph Clonts Alexander, Raymond Wellington Alexander, Richard Griffiss Alexander, Stanley Morton Alexander, William Henry Alexis, Algert Daniel Alford, John Morris Alford, Leon Otto Alford, Lodwick Houston Alford, Zed Dickey Allan, Halle Charles, Jr. Allan, Theodore DeWitt Alldredge, Walter Whitmore Allegrone, Charles Allen, Archer Meredith Ruland Allen, Burrell Clinton, Jr.

Allen, Charles Vern Allen, Edward Henry Allen, Ezra Griffen Allen, James Ross Allen, Jerome Lee Allen, Max Harold Allen, Nelson John Allen, Robert Addison Allen, Roger Hurst Allen, Walter H. Allen, William Young, Jr. Allendorfer, Harry Carl, Jr. Allis, Frederick Ashton Allison, Samuel Francis Almgren, Neal Alston, Augustus Howard, Jr.

Allshouse, Thomas James Altmann, Richard Gustaf Alvarez, Everrett, Jr. Alvis, Harry James Alvis, John Hubbard Amberson, Julius Martin Ambruster, Stephen Henry Amen, William Thomas Ames Jr. Amme Jr. Ammon, William Bronley. Amsden, William Faulkner Ancrum, William Anderson, Anton B.

Anderson, Bern. Anderson, Carl Eric. Anderson, Charles Carter. Anderson Jr. Anderson, Clyde B. Anderson, Edward A. Anderson, Edward L. Anderson, Edwin Alexander [Archive's copy].

Anderson, Fernald P. Anderson, Franklin W. Anderson, Herbert Augustus. Anderson, Herbert H. Anderton Jr. Anderson, Jay S. Anderson, Joseph B. Anderson, Kenneth L. Anderson, Norman O. Anderson, Paul R. Anderson, Richard Beatty. Anderson, Richard E.

Anderson, Robert H. Anderson, Roy G. Anderson, Samuel C. Anderson, Thomas Carlyle. Anderson, Vernon L. Anderson, Walter Stratton. Anderson, William Donald. Anderson, William L. Anderson, William R. Andrews, Adolphus Andrews, Burton H. Andrews, Cecil L. Andrews, Charles H. Andrews, Charles Lee Jr. Andrews, Clyde C. Andrews, Edger C. Andrews, Frank A. Andrews Jr. Andrews, Mark Edwin. Andrews, Philip. Andrews, Richard S. Andrews, Walter Edwards.

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Badt, Harry A. Baer, Donald G. Bagdanovich, Michael P. Baggaley, William. Bagley, David H. Bagley, Harry H. Bahm, George, Henry. Bailey, Carlos Augustus. Bailey, Charles S.

Bailey, John. Bailey, Leonard W. Bailey, Watson Osgood. Bailey, William B. Bains, George Washington. Baird, A. Baird, Leonard J. Bakenhus, Reuben E.

Baker, Charles Adams. Baker, Douglas. Baker, Duncan Scott. Baker, Felix Locke. Baker, Guy Evans. Baker, Harold D. Baker, Harold Edward. Baker, Robert L. Baker, Robert N. Baker, Wilder Dupuy. Baker, William B. Bakke, Harlan J. Bakutis, Fred E. Baldridge, Harry Alexander. Baldwin, Frank.

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Ballentine, John J. Ballinger, John M. Ballinger, Richard Robert. Baltazzi, Harry Warner. Banks Jr. Bannerman, Graeme. Bantz, Fred A. Barbaro, Joseph Raphael. Barbee Jr. Barber, Ernest Hayes. Barbey, Daniel E. Barchet, Stephen G. Bard, Nathan Wayne. Bard, Ralph A. Bardshar, Fredric A. Barham, Eugene A. Barnhart, Robert E.

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Bartlett, James V. Bartlett, John R. Bartlett, Lewis C. Bartol, John Alfred. Barton, John Kennedy. Barton, Leroy L.

Barton, Wilbur G. Bass, Ivan Ernest. Bass, Raymond H. Bassett, Claude Oscar. Bassett Jr. Bassett, Melvin Hughes. Bassler, Robert E. Batchelder, Robert Fred. Batcheller, Edgar H. Batchellor, John K. Bates, Ralph. Bates, Richard Waller. Battle Jr.

Bauch, Charles E. Bauer, George William. Bauer Rudolph C. Bauer, Louis H. Bauernschmidt, George W. Baugh Sr. Baughman, Courtlandt C.

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Benjes Jr. Bennehoff, Olton Rader. Benner, Stanley Graves. Bennet, Floyd. Bennett II, Rawson. Bennett, Andrew Carl. Bennett, Bradley F. Bennett, Carter L. Bennett, Earl Robert. Bennett, Earle. Bennett, Edward L. Bennett, Fred G. Bennett, John E. Bennett Jr. Bennett, Walter F. Bennington, John Paige.

Bennion, Mervyn Sharp. Benson, Francis Wyse. Benson, Howard H. Benson, Lloyd G. Benson, Roy Stanley. Benson, Victor G. Benson, William Howard. Bentley, James A. Bentley, James C. Benton, Hugh A. Berg, Winferd E. Bergen, Franklin S. Bergen, John J. Bergeson, Andrew Harold. Bergin, Charles K. Bergin, Daniel E. Bergner, Allen A. Bergstedt, William C.

Bergstrom, Edward W. Berkey, Russell Stanley. Berkheimer, Jack S. Berkley, Joseph Berzowski. Berkley, William Leneave. Berkner, Lloyd V. Berley, Ferdinand V. Bernard, Lawrence G.

Bernatitus, Ann A. Berndston, Arthur H. Berner, Warren Kenneth. Bernet, Howard C. Bernhard, Alva Douglas. Berns Jr. Bernstein, Henry Emil - Berree, Norman R.

Berrey, Julius M. Berrien, Frank Dunn - Berry Fredric A. Berry Jr. Berry, Charles Joseph. Berry, Fred T. Berry, Ralph B. Bertelli, Perter. Bertelsen, Viggo C.

Bertholf Charles M. Berthold, Elmer E. Berthrong, Raymond. Bertoglio, Floyd J. Bertoglio, Lloyd W. Bertolet, Samuel. Bertschy, Robert S. Berude, John B. Besbekos, George A. Beshany, Philip A. Besson Jr. Best, William A. Bethea, James S. Betts, Sherman W. Beuret, John D. Bevan, George R. Beveridge, Richard A. Bewick, James V. Beyer Jr. Beyerly, Irwin Forest. Bibby, Lowe Hayden. Biddle, Edward. Biederman, Karl J. Bieg, Valentine N. Bienia, John P. Bierer Jr. Bierer, James S. Bieri, Bernhard Henry.

Bieri Jr. Biesemeier, Harold. Bigelow, Elmer C. Biggs, Burton B. Bigley, Thomas J. Bill Jr. Billingsley, William Devotie. Binford, Thomas H.

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