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341. Post-fielding Surveillance of a Guideline-based Decision Support System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Chan.pdf
     January 01, 2004 - Goldstein Abstract Quality assurance (QA) processes for new technologies are used to ensure safety … Based on this experience, new technologies for improving patient safety should include mechanisms for … Advances in Patient Safety: Vol. 1 334 Figure 1. … Patient safety in guideline-based decision support for hypertension management: ATHENA DSS. … Application of new methods to drug safety surveillance: beyond spontaneous reports.

342. Mixed Methods Analysis of Medical Error Event Reports: 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/vol2/Harris.pdf
     June 30, 2004 - Main Abstract Objective: The Applied Strategies for Improving Patient Safety (ASIPS) collaborative … Ongoing safety reporting systems expand and evolve as new event reports are received. … compendium.18 Advances in Patient Safety: Vol. 2 142 Figure 1. … reporting system to inform the development of patient safety interventions. 1. … Advances in Patient Safety: Vol. 2 144 2.

343. Development and Implementation of The University of Texas Close Call Reporting System (pdf file)
     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). … • Patient Safety Reporting System (PSRS). … Advances in Patient Safety: Vol. 2 154 Table 1. Primary information categories a. … Building safety into ICU care. J Crit Care 2002;17(2):78–85. 8. … Confidential incident reporting systems create vital awareness of safety problems.

344. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
     April 01, 2004 - Introduction Why is immunization safety research important? … How are immunization safety data collected? … How do case definitions assist the safety assessment of medical interventions? … Advances in Patient Safety: Vol. 2 92 F ig u re 1 . … Advances in Patient Safety: Vol. 2 102 46.

345. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - problems—as well as patient safety problems that are yet unknown. … A systems approach to surgical safety. Surg Endosc 2002 Jan 8;16:1005–14. 12. … Beckley, WV: Dept. of the Interior, National Mine Safety Academy; 1978. … VA National Center for Patient Safety. … Patient safety standards—hospitals.

346. Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Daudelin.pdf
     January 01, 2000 - Selker Abstract Information Technology (IT) solutions to patient safety/medical error problems are … Many current IT applications for patient safety are focused on hospital processes, such as physician … Advances in Patient Safety: Vol. 3 8 Introduction Acute coronary syndrome (ACS) and the synonymous … Advances in Patient Safety: Vol. 3 14 Figure 5. … for quickly compiling data into one system for use in a patient safety system.

347. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
     February 09, 2005 - White Abstract Clinical decision support (CDS) systems show promise for enhancing patient safety, … If “all politics is local,” then much of patient safety research is localized as well. … Advances in Patient Safety: Vol. 3 406 Table 2. … Improving safety with information technology. N Engl J Med 2003;348(25): 2526–34. 3. … Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.

348. Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/McNeill.pdf
     January 01, 2004 - patient safety; and (6) patient safety research dissemination Advances in Patient Safety: Vol. 3 … Improvement Corps, improving the culture of safety in hospitals, and patient safety reporting. … The field staff include hospital patient safety officers and those responsible for patient safety reporting … Culture of safety AHRQ has developed a Hospital Survey on Patient Safety Toolkit to assess the culture … Patient safety reporting systems AHRQ supports the development of safety reporting systems that can

349. Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Chan.pdf
     July 01, 2004 - Medication safety research Collectively, the datasets have been referred to as the first Patient Safety … research as well as non-Patient Safety research. … Advances in Patient Safety: Vol. 2 236 Table 5. … Advances in Patient Safety: Vol. 2 238 References 1. … Data elements in the HMO Research Network Patient Safety dataset Table 3.

350. A Conceptual Model for Disclosure of Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
     January 01, 2004 - Spiritus, Craig Keenan, Gregory Seymann, Kaveh Sojania, Neil Wenger Abstract Objective: Patient safety … Critical steps toward improving the safety of the health care system include ensuring that the system … Advances in Patient Safety: Vol. 2 484 system is aware of its errors. … Advances in Patient Safety: Vol. 2 488 Table 1. … UCLA Healthcare Center for Patient Safety (LH) and Ethics Center (NW).

351. Systemwide Deployment of Medical Team Training: Lessons Learned in the 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/King.pdf
     January 01, 2002 - King, Beth Kohsin, Mary Salisbury Abstract Advancing to a culture of safety requires a systems change … Teamwork, a powerful patient safety tool, can achieve this goal. Lessons learned within the U.S. … Air Force Patient Safety Program, Bolling Air Force Base (BK). … Innovations in patient safety: multi-disciplinary teamwork training in the operating room. … DoD Patient Safety Award Application, 2003– 04. 8. Kotter JP, Cohen DS.

352. Taxonomic Guidance for Remedial Actions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - Conclusion: This system could assist when addressing safety problems. … The facility had a problem with preventive maintenance of its Advances in Patient Safety: Vol. 2 … As in the Eindhoven taxonomy, slips Advances in Patient Safety: Vol. 2 80 Figure 1. … A Advances in Patient Safety: Vol. 2 82 Figure 3. … Medication Safety Alert, June 2, 1999.

353. Medical Injury Identification Using Hospital Discharge Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
     January 01, 2003 - on in-hospital patient safety problems. … It provides a more accurate estimate of the full scope of patient safety problems. … Patient safety efforts should focus on medical injuries. JAMA 2002;287(15):1,993–7. 3. … Patient safety indicators: using administrative data to identify potential patient safety concerns. … Advances in Patient Safety: Vol. 2 132 23.

354. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     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 - A total of 16 Advances in Patient Safety: Vol. 2 398 Figure 1. … Reliab Eng and Syst Safety 1998;59:187–99. 14. Brown A, Haugene B. … Reliability Eng and Syst Safety 1994;45:139–57. 16. Linnerooth-Bayer J, Wahlstrom B. … Comprehensive patient safety programs in health care settings. … Statewide patient safety coalitions: a status report.

355. Looking for Trouble in All the Right Places: The Legal Implications Associated with “Electronic Signatures” and High-risk Clinical Situations (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Escobar.pdf
     February 01, 2005 - Advances in Patient Safety: Vol. 3 56 T a b le 2 . … research and societal attention to patient safety. … session at the National Patient Safety Foundation’s Annenberg Conference on Patient Safety, in Indianapolis … Aviation Safety Reporting System. … In: Peer review and mediation to promote patient safety. Houston J.

356. Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf
     January 01, 2004 - clinical guideline and working to promote an evidence-based intervention aimed at improving patient safety … focused on the dissemination strategies for clinical guidelines.2–4 However, Advances in Patient Safety … of the intensive care Advances in Patient Safety: Vol. 3 296 environment.21 The perioperative … Advances in Patient Safety: Vol. 3 300 Engagement of department leaders A critical factor that … Making health care safer: a critical analysis of patient safety practices.

357. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
     November 29, 2004 - related to drug-drug interactions, use of contraindicated drugs, or failure to obtain recommended safety … Advances in Patient Safety: Vol. 1 372 Automated pharmacy data was used to ascertain names, dates … Advances in Patient Safety: Vol. 1 374 Table 2. … Jt Comm J Qual Safety. 2004;30(1):15–24. 10. Dovey SM, Meyers DS, Phillips RL, Jr., et al. … Advances in Patient Safety: Vol. 1 380 16. O’Connor P, Rush W, Pronk N, et al.

358. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
     July 01, 2003 - Introduction During the millennium period, the issue of patient safety was elevated to national focus … An integral part of this value system is the promotion of a culture of safety. … These two committees oversee the patient safety aspects of the ACPOE implementation. … National observational study of prescription dispensing accuracy and safety in 50 pharmacies. … Advances in Patient Safety: Vol. 2 198 19.

359. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - or misuse of therapies, and adverse events attributable to clinical inertia Advances in Patient Safety … Advances in Patient Safety: Vol. 2 296 Prevalence and cost of clinical inertia Prevalence It … Advances in Patient Safety: Vol. 2 302 The recommended visit interval of 3–6 months for those with … Advances in Patient Safety: Vol. 2 308 47. Pellegrini F, Belfiglio M, De Berardis G, et al. … Advances in patient safety: from research to implementation.

360. Barriers Associated with Medication Information Handoffs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
     January 01, 2004 - Making health care safer: a critical analysis of patient safety practices. … Making health care safer: a critical analysis of patient safety practices. … AHRQ’s patient safety initiative. Building foundations, reducing risk. … safety/npsg.htm. … Technology and safety: a two- edged sword.