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321. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/cdifftoolkit/index.html
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322. Medliabrep
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/liability/medliabrep.html
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323. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/index.html
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324. Hais60121
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/hais60121.html
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325. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/prosafetysum/index.html
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326. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/index.html
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327. Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Seger.pdf
     January 01, 2003 - demonstrated that the ADE monitor that they used required substantially fewer Advances in Patient Safety … have a well-tested monitor that can eventually be used for measurement purposes such as medication-safety … Advances in Patient Safety: Vol. 2 176 In this study, ADEs were defined as events related to medication … receiving greater than 5 consecutive days of ketorolac Misc. duration Advances in Patient Safety … Advances in Patient Safety: Vol. 2 182 While this methodology was able to discover many events, there

328. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
     January 01, 2005 - Advances in Patient Safety: Vol. 2 386 Figure 4. … Advances in Patient Safety: Vol. 2 390 mistake and potential consequences of the error. … A presentation at the national Summit on medical errors and patient safety research. … http://www.jcaho.org/accredited+organizations/patient +safety/npsg.htm. 7. … Advances in Patient Safety: Vol. 2 394 36. Frankel RM, Devers K.

329. Observing Nurse Interaction with Infusion Pump Technologies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Carayon.pdf
     January 01, 2004 - Advances in Patient Safety: Vol. 2 360 F ig u re 1 . … Human factors in healthcare: benefiting worker/patient safety and quality. … Making health care safer: a critical analysis of patient safety practices. … Technology and patient safety: a two-edged sword. … Reducing workload and increasing patient safety through work and workspace design.

330. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
     February 12, 2004 - The system has helped to identify patterns of patient safety errors and areas where patient safety events … patient safety newsletters (available on the DoD patient safety Web site), patient safety hot topic … Center MHSPSR: Military Health System Patient Safety Registry Advances in Patient Safety: Vol. … Center PSO/M: Patient Safety Officer /Manager PSR: Patient Safety Registry PSWG: Department of … Defense Patient Safety Work Group QuIC: Quality Interagency Coordination Task Force SAC: Safety

331. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - From this frame large, medium, Advances in Patient Safety: Vol. 3 226 and small facilities as … Some facilities also ask to include quality managers or patient safety managers. … sites, and for MedSun authorized reporters.5 FDA Patient Safety News. … Device Safety Exchange (DS-X). … It also is vital to provide useful feedback so patient safety may be improved.

332. Cost Effectiveness of a Multifaceted Program for Safe Patient Handling (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Siddharthan.pdf
     January 10, 2005 - Introduction The National Institute for Occupational Safety and Health identifies back injury as the … Author affiliations Patient Safety Center of Inquiry, James A. … Address correspondence to: Kris Siddharthan, Ph.D., Patient Safety Center, James A. … Veterans Administration, Office of Occupational Safety and Health. … Advances in Patient Safety: Vol. 3 358 16. Berk A, Paringer L, Mushkin SJ.

333. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schillinger.pdf
     January 01, 2004 - Advances in Patient Safety: Vol. 2 200 Drugs, such as oral anticoagulants, that have a narrow therapeutic … Advances in Patient Safety: Vol. 2 202 We obtained patients’ indications for chronic anticoagulation … Advances in Patient Safety: Vol. 2 210 Acknowledgments This research was supported through grants … Medication safety: moving from illusion to reality. JAMA 2003;289(9):1154–6. 33. … Advances in Patient Safety: Vol. 2 212 46. Smedley BD, Stith AY, Nelson AR.

334. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
     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 - Advances in Patient Safety: Vol. 2 216 Barriers to safe pediatric prescribing Off-label use of … MICROMEDEX20 Safety and effectiveness in children not established. … Advances in Patient Safety: Vol. 2 218 Discrepancies in dosing recommendations The problem of … Pediatric drug labeling: improving the safety and efficacy of pediatric therapies. … FDA questions antidepressant safety for children. Lancet 2003 Nov 8;362(9395):1558 20.

335. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
     April 09, 2004 - Advances in Patient Safety: Vol. 3 140 Table 2. … Patient Safety Conference The NYSDOH will hold a statewide Patient Safety Conference to disseminate … Patient safety: achieving a new standard of care. … /safety/iom_response3.php. 11. … Patient Safety Reporting System.

336. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
     January 01, 2004 - problem of medical errors and laid out a fairly elaborate set of recommendations whereby patient safety … Patients have a Advances in Patient Safety: Vol. 3 372 right to know their past and present medical … Yet, I have been Advances in Patient Safety: Vol. 3 374 unable to locate any case in which an … against it, its total payouts to settle or resolve these claims were in the Advances in Patient Safety … Advances in Patient Safety: Vol. 3 380 Author affiliation Center for Ethics, Emory University, Atlanta

337. Learning from Errors in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
     February 01, 2004 - Three members of the research team (one pediatrician and two patient safety researchers) independently … Prior patient safety studies in ambulatory and in-patient adult populations have demonstrated that … (Problem type: Communication) Advances in Patient Safety: Vol. 1 364 Table 5. … Pediatric patient safety in the ambulatory setting. Ambul Pediatr 2004;4:47–54. 8. … Patient safety problems in children’s medical care: a Critical Incident Analysis.

338. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     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 - The impact of diagnostic failure on patient safety does not appear to have been fully recognized. … Advances in Patient Safety: Vol. 2 244 The word “bias” originally was used in the game of bowls to … Advances in Patient Safety: Vol. 2 246 Impact of affective state Physicians and caregivers are … Advances in Patient Safety: Vol. 2 254 38. Poses RM, Cebul RD, Collins M, et al. … Safety errors in emergency medicine. In: Markovchick VJ, Pons PT, editors.

339. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
     January 01, 2005 - Advances in Patient Safety: Vol. 2 264 Figure 1. … Advances in Patient Safety: Vol. 2 272 T ab le 4 . … How the public perceives patient safety. … Administrative data based patient safety research: a critical review. … Advances in Patient Safety: Vol. 2 278 82. McDonald J.

340. Identifying Barriers to the Success of a Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
     March 01, 2004 - A team of researchers at the University of Texas Center of Excellence for Patient Safety Research and … (See Table 2 for a list Advances in Patient Safety: Vol. 3 174 Table 2. … To err is human: building a safety health system. … The Patient Safety Reporting System. … Aviation safety reporting program. Federal Aviation Administration, Advisory Circular 00-46B.