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5801. Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Shimada_65.pdf
      April 04, 2008 - Data Data were obtained from two VHA administrative databases: the VHA Medical SAS Inpatient Data Files … [also known as the Patient Treatment Files (PTF)], and the VHA Medical SAS Outpatient Data Files (also … known as the Outpatient Care Files). … preparation for running the PSI software, as described previously.8 Data from the Outpatient Care Files

5802. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
      May 06, 2008 - Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization Paul Conlon, PharmD, JD; Rebecca Havlisch, RN, JD; Narendra Kini, MD, MSHA; Christine P…

5803. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
      January 01, 2007 - Voluntary Adverse Event Reporting in Rural Hospitals Voluntary Adverse Event Reporting in Rural Hospitals Charles P. Schade, MD, MPH; Patricia Ruddick, MSN, APRN-BC; David R. Lomely, BS; Gail Bellamy, PhD Abstract Since 2004, we have managed a voluntary Web-based medical adverse event (AE) reporting system …

5804. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
      April 21, 2008 - Patient Safety Learning Pilot: Narratives from the Frontlines Patient Safety Learning Pilot: Narratives from the Frontlines Shirley E. Kellie, MD, MSc; James B. Battles, PhD; Nancy M. Dixon, PhD; Harold S. Kaplan, MD; Barbara Rabin Fastman, MHA Abstract Although patient safety experts have focused on event…

5805. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
      April 04, 2008 - A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care Ranjit Singh, MA, MB, BChir (Cantab.), MBA; Wilson Pace, MD; Ashok Singh, MA, MB, BChir (Cantab); Chester Fox, MD; Gurdev Singh, MSc…

5806. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-West_102.pdf
      March 31, 2008 - Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative David R. West, PhD; Wilson D. Pace, MD; L. Miriam Dickinson, PhD; Daniel M. H…

5807. Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Riley_59.pdf
      April 06, 2008 - Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act William Riley, PhD; Bryan A. Liang, MD, PhD, JD; William Rutherford, MD; William Hamman, M…

5808. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
      March 03, 2008 - A Model of Care Delivery to Reduce Falls in a Major Cancer Center A Model of Care Delivery to Reduce Falls in a Major Cancer Center Nancy E. Kline, PhD, RN, CPNP, FAAN; Bridgette Thom, MS; Wayne Quashie, MPH, RN; Patricia Brosnan, MPH, RN; Mary Dowling, MSN, RN Abstract Falls are a leading cause of injuries…

5809. Common Cause Analysis: Focus on Institutional Change (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
      January 20, 2008 - Common Cause Analysis: Focus on Institutional Change Common Cause Analysis: Focus on Institutional Change Anne Marie Browne, MSN, RN; Robert Mullen, PharmD; Jeanette Teets, MSN, CRNP, RN; Annette Bollig, MSN, RN; James Steven, MD, SM Abstract The Children’s Hospital of Philadelphia has created a mechanism …

5810. Measuring Safety Climate in Primary Care Offices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-SinghG_67.pdf
      April 14, 2008 - Measuring Safety Climate in Primary Care Offices Measuring Safety Climate in Primary Care Offices Gurdev Singh, MscEng, PhD; Ranjit Singh, MA, MB, BChir (Cantab), MBA; Eric J. Thomas, MD, MPH; Reva Fish, PhD; Renee Kee, MS; Elizabeth McLean-Plunkett, MA; Angela Wisniewski, Pharm D; Saburo Okazaki, MD; Diana Anders…

5811. The PeaceHealth Ambulatory Medication Safety Culture Survey (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stock_72.pdf
      January 01, 2007 - The PeaceHealth Ambulatory Medication Safety Culture Survey The PeaceHealth Ambulatory Medication Safety Culture Survey Ronald Stock, MD; Eldon R. Mahoney, PhD Abstract Objective: The objective of this project was to construct a measure of medication safety culture in ambulatory settings. Methods: A 16-it…

5812. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
      March 19, 2008 - Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process Beverly Ann David, PhD; Ana Rodriguez, PharmD; Stanley W. Marks, MD Abstract There is an urgent need to m…

5813. Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hagg_80.pdf
      January 01, 2007 - Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption Heather Woodward Hagg, MS; Jamie Workman-Germann, MS; Mindy Flanagan, PhD; Deanna Suskovich, BA; Susan Schachitti, MBA; Christine Corum, MS; Bradley N. Do…

5814. TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-King_1.pdf
      April 07, 2008 - TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety Heidi B. King, MS, CHE; James Battles, PhD; David P. Baker, PhD; Alexander Alonso, PhD; Eduardo Salas, PhD; John Webster, MD, MBA; Lauren Toomey, RN,…

5815. Prologue: The Shift toward Performance and Tools (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Prologue_Keyes_Vol3.pdf
      June 02, 2025 - Prologue: The Shift toward Performance and Tools Prologue The Shift toward Performance and Tools Margaret A. Keyes, M.A. The articles in this volume provide a number of perspectives on performance and tools used to improve the safe delivery of health care. They include a wide variety of approaches that …

5816. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
      March 27, 2008 - The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures 1 The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures Lawrence L. Faltz, MD, FACP; John N. Morley, MD, FACP…

5817. The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Jones_29.pdf
      February 23, 2008 - The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs Katherine J. Jones, PT, PhD; Anne Skinner, RHIA; Liyan Xu, MS; Junfeng Sun, PhD; Keith Mueller, PhD A…

5818. Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hannah_23.pdf
      February 24, 2008 - Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture Karen L. Hannah, MBA; Charles P. Schade, MD, MPH; David R. Lomely, BS; Patricia Ruddick,…

5819. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
      January 22, 2008 - Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World Stephen M. Borowitz, MD, Linda A. Waggoner-Fountain, MD, Ellen J. Bass, PhD, and Justin M. DeVoge, MS Abstract Background: Sign-out is a …

5820. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
      March 31, 2008 - Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care Amy J.H. Kind, MD; Maureen A. Smith, MD, MPH, PhD Abstract Objectives: The Joint Commission mandates that six c…