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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Fried.pdf
January 01, 2003 - The Use of Surgical Simulators to Reduce Errors
165
The Use of Surgical Simulators
to Reduce Errors
Marvin P. Fried, Richard Satava, Suzanne Weghorst,
Anthony Gallagher, Clarence Sasaki, Douglas Ross,
Mika Sinanan, Hernando Cuellar, Jose I. Uribe,
Michael Zeltsan, Harman Arora
Abstract
The training of…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
January 01, 2004 - Hunt et al.,22 for example, conducted a systematic review of 15
studies that examined the efficacy of … Similarly, a review
of studies addressing the impact of clinical pharmacists in preventing medication … computer-based clinical decision support systems on
physician performance and patient outcomes: a
systematic review … Computer
support for determining drug dose: systematic review
and meta-analysis.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
March 01, 2004 - This review resulted in the following summaries:
• Aviation Safety Reporting System (ASRS). … designed for reporting all
nonaccidents (close calls), it provides an opportunity for more
prospective review … Review of the reporting system was
conducted again using standard human-factors methodology for computer
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
January 01, 2004 - pediatric service, compared with 4.12 per 1,000 orders on the adult medical
service.8 In a pharmacy-based review … and complete
prescription information, to accurately describe errors without a formal, costly
chart review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bonner.pdf
January 01, 2004 - This review revealed significant gaps and implementation
difficulties. … , workgroup members developed or adapted
site-specific policies as needed based on the initial CWG review … The “Plan” stage involved development of the
workgroup and review of the existing site policies. … “Study”
After researching policies at their respective institutions, workgroup members
met to review … This
policy was reviewed and approved by institutional review boards at participating
sites.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
January 01, 2004 - A literature review was completed using online search
engines such as MEDLINE®, the Cumulative Index … Tracheostomy care literature review
Author Subject Grade
Elpern, et al. (1994) Aspiration IV A … After completing a thorough
literature review and collecting the staff knowledge data, work commenced … Systematic Review #9. … Tracheostomy care literature review
Figure 1.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Miranda.pdf
July 01, 2004 - The basis for the fact sheet was a larger set of
messages drawn from a review of the health care literature … might help to prevent medical errors, the Agency for
Healthcare Research and Quality (AHRQ) launched a review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
March 01, 2004 - Methods: We conducted a
systematic review of literature from the past 6 years, identifying research … We limited our search in an effort to
build on the thorough review conducted by Pierce that covered … Step 2: Primary review
of abstracts, applying
content criteria, n=84. … However, our review of the literature did
identify three important lessons. … Arriving at such consensus was beyond the scope of this review.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - typically arise in the course of diagnostic test evaluation: verification or
work-up bias, diagnostic review … bias, test review bias, and incorporation bias.20
Generally, the action that results from CDRs takes … everything, however trivial
• Discuss with others and record their comments and observations
• Review … It is important to review and understand the CDRs and ADRs,
and to examine and apply them in the context
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
January 01, 2003 - reaches
the wrong patient)
Physician
ordering
Medication
order written in
wrong chart
Nurse review … of order
Pharmacy review of
order
Verbal discussion of
medication with patient
Medication administered
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/West.pdf
September 01, 2005 - The
group met regularly to review data, direct additional study, and provide policy
oversight. … identified and discussed the
epidemiology of errors within the specific medical error domain under
review … returned regularly to further observe the changes effected by the
interventions and gather data for review … - Assure that providers review results and act in a timely
manner. … Identifying
adverse drug events: Development of a computer-
based monitor and comparison with chart review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Furmaga.pdf
January 01, 2005 - First assessment and intervention
A utilization review, stratified by individual VA medical center … Advances in Patient Safety: Vol. 3
280
A follow-up utilization review was completed in March 2001 … Third assessment and intervention
In February 2004, a third review was completed. … Final assessment and intervention
In May 2004, a fourth and final review was completed on the patients … After careful review of the medical record and
discussion with the prescribing physician, it was felt
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Savino.pdf
July 01, 2003 - Review of the continuing medical education (CME) literature
revealed that efforts to modify physician … Protocol for Surgical Infection Prophylaxis
269
the videotapes of the sessions and/or review the … In rare cases of noncompliance, departmental peer review was
conducted by QCRM staff. … Personnel were
trained on how to collect the data, review charts, and analyze data. … The implementation of a concurrent review mechanism is key to early
identification of noncompliance.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keller.pdf
January 01, 2004 - An Internet-based
tracking interface enables personnel to review their assigned alerts, determine
whether
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
May 01, 2003 - conferences are a way for medicine to self-regulate and for
physicians to participate in their own quality review … reported by students should be integrated into discussions in courses that
allow students to critically review … reporting often gave a glimpse of the extreme and egregious types of medical
errors, but an incomplete review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Nieva.pdf
January 07, 2005 - This slow pace is the result of a research supply model that takes research
through various cycles of review … No magic
bullets: a systematic review of 102 trials of
interventions to improve professional practice
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Ramanujam.pdf
January 01, 2003 - follows is
informed by previous research, it is not intended to serve as a comprehensive
literature review … members of the guiding coalition in the supporting
structures set up to implement change; more frequent review … require new team structures that include physicians, nurses, pharmacists, and
dieticians in joint review … rely on committees that are already in place, such as the pharmacy and
therapeutic committees, to review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Shaha.pdf
May 01, 2004 - industry
standards for outcomes, and all impacts were evaluated statistically—
not by superficial review
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
May 19, 2003 - Outcome
As a result of the review, a simplified heparin dosing computer interface that
incorporated
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Galt.pdf
January 01, 2004 - A review of the health and technology literature at the time of this work
revealed few reports that