1Resar R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia[J]. Jt Comm J Qual Pa- tient Saf,2005,31(5) :243-248.
2Cross R, Baird L. Technology is not enough~ improving performance by building organizational memory [J]. Sloan Manag Rev, 2000,21 (3) : 24-27.
3Darling M, Parry C, Moore J. Learning in the thick of it[J~. Harv Bus Rev,2005,83(7) :84-92.
4Ellis S, Davidi I. A{ter-event reviews: drawing lessons from successful and failed experience[J ] Appl Psy- chol, 2005,90(5) : 857-871.
5Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy[J]. Arch Intern Med, 2003, 163(1) :83-90.