Marjon Borgert

226 Chapter 10 38. Hughes RG. Patient Safety and Quality. An Evidence-Based Handbook for Nurses . Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. 39. Henriksen K, Battles JB. Research on medical error gaining momentum. Hum Factors Bul. 2001;44:1-5. 40. Vincent C, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Qual Saf. 2014;23:670–677. 41. Kennedy I. Learning from Bristol. Cmnd5207. Dept of Health, London: HMSO; 2001 42. Group of WHO Patient Safety. Human Factors in patient Safety. Review of Topics and Tools. World Health Organization (WHO); 2009. 43. Cooper D. Improving Safety Culture: a Practical Guide. Applied Behavioural Sciences, Hull, 2001. Available at: http://www.behavioral-safety.com/articles/Improving_safety_culture_a_ practical_guide.pdf 44. Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Quality and Safety in Health Care. 2005;14:231-233. 45. Pronovost P.J, Berenholtz S.M, Needham, D.M. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:a1714. 46. Pronovost PJ, Berenholtz SM, Ngo K, et al. Developing and pilot testing quality indicators in the intensive care unit. J Crit Care. 2003;18:145-55. 47. De Vos M, Graafmans W, Keesman E, Westert G, Van der Voort PH. Quality measurement at intensive care units: which indicators should we use? J Crit Care. 2007;22:267-74. 48. Hickey A, Scott I, Denaro C, Stewart N, Bennett C, Theile T. Using clinical indicators in a quality improvement programme targeting cardiac care. Int J Qual Health Care. 2004;16(Suppl 1):i11-i25. 49. Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality; 2008. 50. Niedner MF, Muething SE, Sutcli e KM. The high-reliability pediatric intensive care unit. Pediatr Clin North Am. 2013;60:563-80. 51. Chassin MR, Loeb JM. High-Reliability Health Care: Getting There from Here. The Milbank Quarterly. 2013;3:459–490. 52. Weick, KE, Sutcli e KM. Managing the Unexpected. 2nd ed. San Francisco: Jossey-Bass; 2007. 53. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II : A White Paper. The Resilient Health Care Net: Published simultaneously by the University of Southern Denmark, University of Florida, USA, and Macquarie University, Australia; 2015. 54. Braithwaite J, Wears RL, Hollnagel E. Resilient health care: turning patient safety on its head. Int J Qual Health Care. 2015;27:418-20.