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5841. Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gandhi_22.pdf
      February 01, 2007 - Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record Tejal K. Gandhi, MD, MPH; Nancy L. Keating, MD, MPH; Matthew Ditmore; David Kiernan; Robin Johnson; Elisabeth Burdick, MS; Claus Ham…

5842. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
      April 07, 2008 - Available at: www.ashrm.org/ashrm/resources/files/FMEAwhitepap er.pdf. Access April 7, 2008. 5. … Patient Saf 2007; 33: 549-558. 14 mailto:riley001@umn.edu http://www.ashrm.org/ashrm/resources/files … /FMEAwhitepaper.pdf http://www.ashrm.org/ashrm/resources/files/FMEAwhitepaper.pdf http://www.webmm.ahrq.gov

5843. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
      April 02, 2008 - The Nature, Characteristics and Patterns of Perinatal Critical Events Teams The Nature, Characteristics and Patterns of Perinatal Critical Events Teams William Riley, PhD; Helen Hansen, PhD, RN; Ayse P. Gürses, PhD; Stanley Davis, MD; Kristi Miller, RN, MS; Reinhard Priester, JD Abstract The Institute …

5844. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
      March 27, 2008 - High-Hanging Fruit: Improving Transitions in Health Care High-Hanging Fruit: Improving Transitions in Health Care Shawna J. Perry, MD; Robert L. Wears, MD, MS; Emily S. Patterson, PhD Abstract Discussions about enhancing the safety of transitions in health care have been disjointed. Respected health care …

5845. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
      February 21, 2008 - Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program Brian Jack, MD; Jeffrey Greenwald, MD; Shaula Forsythe; Julie O'Donnell; A…

5846. Using Data Mining to Predict Errors in Chronic Disease Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-McCabe_39.pdf
      March 28, 2008 - Using Data Mining to Predict Errors in Chronic Disease Care Using Data Mining to Predict Errors in Chronic Disease Care Ryan M. McCabe; Gediminas Adomavicius, PhD; Paul E. Johnson, PhD; Gregory Ramsey; Emily Rund; William A. Rush, PhD; Patrick J. O’Connor, MD, MPH; JoAnn Sperl-Hillen, MD Abstract Develop…

5847. 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
      January 01, 2006 - 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive in a Single Hospital? 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma®, and Team Training All Thrive …

5848. Impact of Staff-Led Safety Walk Rounds (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Montgomery_42.pdf
      March 05, 2008 - Impact of Staff-Led Safety Walk Rounds Impact of Staff-Led Safety Walk Rounds Vicki L. Montgomery, MD, FAAP, FCCM Abstract Objectives: The primary objectives of this study were to provide a venue for discussing safety concerns and to facilitate finding solutions for everyday safety issues. Methods: The mul…

5849. Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Woods_78.pdf
      July 23, 2008 - Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions Donna M. Woods, EdM, PhD; Jane L. Holl, MD, MPH; Denise Angst, PhD, RN; Susan C. Echiverri, MD; Daniel Johnson, MD; David F. Soglin, MD; Gop…

5850. The Mobile Mock Operating Room: Bringing Team Training to 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/vol3/Advances-Paige_6.pdf
      January 24, 2008 - The Mobile Mock Operating Room: Bringing Team Training to the Point of Care The Mobile Mock Operating Room: Bringing Team Training to the Point of Care John T. Paige, MD; Valeriy Kozmenko, MD; Tong Yang, MD, MS; Ramnarayan Paragi Gururaja, MD; Isidore Cohn, Jr., MD; Charles Hilton, MD; Sheila Chauvin, MEd, PhD …

5851. Simulation-Based Education Improves Patient Safety in Ambulatory Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
      March 12, 2008 - Simulation-Based Education Improves Patient Safety in Ambulatory Care Simulation-Based Education Improves Patient Safety in Ambulatory Care Beth A. LaVelle, PhD, RN, CEN; Joanne J. McLaughlin, MA, BSN, RN Abstract High-fidelity simulations of patient scenarios have been used successfully to promote critical …

5852. Pillars of a Smart, Safe Operating Room (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Seagull_98.pdf
      April 07, 2008 - Pillars of a Smart, Safe Operating Room Pillars of a Smart, Safe Operating Room F. Jacob Seagull, MD; Gerald R. Moses, PhD; Adrian E. Park, MD Abstract Major gains in patient safety can be achieved through development of innovative approaches to the care of surgical patients. Investigators and clinicians have…

5853. Patient Monitors in Critical Care: Lessons for Improvement (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_16.pdf
      January 01, 2003 - Patient Monitors in Critical Care: Lessons for Improvement Patient Monitors in Critical Care: Lessons for Improvement Frank A. Drews, PhD Abstract Unexpected incidents are common in intensive care medicine. One means of detecting, diagnosing, and treating these events is use of physiologic displays that sho…

5854. Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Leonhardt_35.pdf
      March 15, 2008 - Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach Kathryn Kraft Leonhardt, MD, MPH; Patti Pagel, RN; Deborah Bonin, RHIA, CPHQ; D. Paul Moberg, PhD; Mitchell L. Dv…

5855. The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meyer_41.pdf
      March 03, 2008 - The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems Gregg S. Meyer, MD, MSc; David F. Torchiana, MD; Deborah Colton; James Mountford, MB, BCh; Elizabeth Mort, MD; Sarah Lenz; Nancy Gagliano, MD; Elizabet…

5856. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
      May 05, 2008 - Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients Kshitij P. Mistry MD, MSc; James Jaggers, MD; Andrew J. Lodge, MD; Michael Alton, MSN, RN; Jane M. Mericle, BSN, RN, MHS-CL; Karen S. Frush, MD…

5857. Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Sehgal_64.pdf
      April 02, 2008 - Podcasts—which are digital media files that can be automatically delivered through subscription feeds—have

5858. In Situ Simulation: Challenges and Results (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
      May 05, 2008 - In Situ Simulation: Challenges and Results In Situ Simulation: Challenges and Results Mary D. Patterson, MD; George T. Blike, MD; Vinay M. Nadkarni, MD Abstract In situ simulation, simulation that is physically integrated into the clinical environment, provides a method to improve reliability and safety in h…

5859. Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Dingley_14.pdf
      February 06, 2008 - Improving Patient Safety Through Provider Communication Strategy Enhancements Improving Patient Safety Through Provider Communication Strategy Enhancements Catherine Dingley RN, PhD, FNP; Kay Daugherty RN, PhD; Mary K. Derieg RN, DNP; Rebecca Persing, RN, DNP Abstract The purpose of this study was to devel…

5860. Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gururaja_7.pdf
      January 24, 2008 - Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training Ramnarayan Paragi Gururaja, MD, MPH; Tong Yang, MD, MS; John T. Paige, MD; Sheila W. C…