The Jewish Healthcare Foundation of Pittsburgh. 2002. The Pittsburgh Perfecting Patient Care System: A New Design for Delivering Health. Branches, January:1-16. Branches is a publication of the Jewish Healthcare Foundation; Pittsburgh, PA. [Online]. Available: http://jhf.org/reports/branches/pdfs/bran_jan.pdf.

Thomas E, Orav J, Brennan T. 2000. Hospital ownership and preventable adverse events. Journal of General Internal Medicine 15:211–219.

Thompson J, Bunderson J. In press. Violations of principle: Ideology currency in the psychological contract. Academy of Management Review.

Tucker A, Edmondson A. 2002. Managing routine exceptions: A model of nurse problem solving behavior. Advances in Health Care Management 3:87–113.

Tucker A, Edmondson A. 2003. Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. California Management Review 45(2):1–18.

Tucker A, Edmondson A, Spear S. 2002. When problem solving prevents organizational learning. Journal of Organizational Change Management 15(2):122–137.

VHA. 2003. What Is VHA? [Online]. Available: https://www.vha.com/aboutvha/public/about_whatisvha.asp [accessed May 7, 2003].

Walshe K, Rundall T. 2001. Evidence-based management: From theory to practice in health care. The Milbank Quarterly 79(3):429–458.

Walston S, Kimberly J. 1997. Reengineering hospitals: Evidence from the field. Hospital and Health Services Administration 42(2):143–163.

Walston S, Burns J, Kimberley J. 2000. Does reengineering really work? An examination of the context and outcomes of hospital reengineering initiatives. Health Services Research 34(6):1363–1388.

Ward G, Burns R, Burns K. 1990. The Civil War. Warner Home Video, an AOL Time Warner Company. 1990 DVD Video. A production of Florentine Films and WETA-TV.

Weick K, Roberts K. 1993. Collective mind and organizational reliability: The case of flight operations on an aircraft carrier deck. Administrative Science Quarterly 38:357–381.

Zucker L. 1986. Production of trust: Institutional sources of economic structure, 1840–1920. In: Staw B, Cummings L, eds. Research in Organizational Behavior. Greenwich, CT: JAI Press. Pp. 53–111.

Front Matter (R1-R22)

Executive Summary (1-22)

1 Nursing: Inseparably Linked to Patient Safety (23-52)

2 A Framework for Building Patient Safety Defenses into Nurses' Work Environments (53-64)

3 Nurses Caring for Patients: Who They Are, Where They Work, and What They Do (65-107)

4 Transformational Leadership and Evidence-Based Management (108-161)

5 Maximizing Workforce Capability (162-225)

6 Work and Workspace Design to Prevent and Mitigate Errors (226-285)

7 Creating and Sustaining a Culture of Safety (286-311)

8 Implementation Considerations and Needed Research (312-328)

Appendix A: Committee Membership and Study Approach (329-340)

Appendix B: Interdisciplinary Collaboration, Team Functioning, and Patient Safety (341-383)

Appendix C: Work Hour Regulation in Safety-Sensitive Industries (384-436)

Index (437-462)