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- To Err Is Human: Building a Safer Health System.National Academy Press, Washington, DC1999
- Serious Reportable Events in Healthcare: A Consensus Report.NQF, Washington, DC2002
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- Risk factors for retained instruments and sponges after surgery.N Engl J Med. Jan. 16, 2003; 348: 229-235
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- Bar-coding surgical sponges to improve safety: A randomized controlled trial.Ann Surg. Apr. 2008; 247: 612-616
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- Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center.Langenbecks Arch Surg. Aug. 2006; 391 (Epub Sep. 17, 2005): 390-395
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- Errors prevented by and associated with bar-code medication administration systems.Jt Comm J Qual Patient Saf. May 2007; 33: 293-301
- Prevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness.Surgery. May 2009; 145 (Epub Mar. 21, 2009): 527-535
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Centers for Medicare & Medicaid Services (CMS): Fact Sheet: CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events. http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3224 (last accessed Dec. 7, 2010).
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