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361. Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Teigland.pdf
     March 01, 2004 - Introduction This study, which started in October 2001, is one of the 22 patient safety projects funded … Advances in Patient Safety: Vol. 3 72 Since the only technology requirement for participation was … Advances in Patient Safety: Vol. 3 78 F ig u re 3 . … Patient safety in geriatrics: a call for action. J Gerontol 2003; 58A(9):813–819. 8. … Evaluating the culture of safety. Qual Saf Health Care 2003;12:401. 37.

362. Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database (pdf file)
     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 - established the foundation for subsequent efforts to assess and intervene on potential medication safety … Advances in Patient Safety: Vol. 3 280 A follow-up utilization review was completed in March 2001 … Advances in Patient Safety: Vol. 3 284 Fourth and final intervention An intervention was taken … Advances in Patient Safety: Vol. 3 288 References 1. … New analyses regarding the safety of calcium-channel blockers: a statement for health professional

363. Implementation of an Evidence-based Protocol for Surgical Infection Prophylaxis (pdf file)
     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 - three demonstration projects involving hospital networks that were funded under the New York State Safety … These demonstration projects aim to improve the completeness of Advances in Patient Safety: Vol. … Infection control—a problem for patient safety. N Engl J Med 2003;348:651–6. 2. … Making health care safer: a critical analysis of patient safety practices. … Making health care safer: a critical analysis of patient safety practices.

364. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/Pace.pdf
     January 01, 2004 - Methods: Individuals in 34 primary care practices reported medical errors to a Patient Safety Reporting … From a second view, promoting primary care safety is all about improving communication. … Australian Patient Safety Foundation (APSF). … Organizing patient safety research to identify risks and hazards. … Advances in patient safety: From research to implementation. Vol 2, Concepts and methodology.

365. Cognitive Artifacts’ Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Nemeth.pdf
     July 07, 2002 - Advances in Patient Safety: Vol. 2 280 Figure 1. … Advances in Patient Safety: Vol. 2 292 References 1. Patel VL, Kaufman DR, Arocha JF. … A tale of two stories: contrasting views of patient safety. … Chicago, IL: National Healthcare Safety Council of the National Patient Safety Foundation, American … Going solid: a model of systems dynamics and consequences for patient safety.

366. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - NIH policy for data and safety monitoring. … System changes to improve patient safety. BMJ 2000;320(7237):771–3. 12. … Using aggregate root cause analysis to improve patient safety. … Developing a culture of safety in the Veterans Health Administration. … Making health care safer: a critical analysis of patient safety practices.

367. The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Rudman.pdf
     January 01, 2004 - Immediate steps towards patient safety. Healthc Finance Manage 2004;February:58(2):56–61. … IT, patient safety, and quality care. J Healthc Inf Manag 2002;16(1):28–33. 16. Matthews P. … Patient safety with information technology. N Engl J Med 2003;348(25): 2526–34. 23. … Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. … Jt Comm J on Qual and Safety 2003;23 (4):171–80. 34. Dixon JF.

368. Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Wideman.pdf
     April 20, 2004 - Advances in Patient Safety: Vol. 3 440 Figure 1. … by the VHA National Center for Patient Safety (NCPS). … Advances in Patient Safety: Vol. 3 450 Author affiliations Harry S. … Braun Outlook Safety Infusion System. Health Devices. 2003;32(10):382–95. 18. … Veterans Health Administration National Center for Patient Safety (NCPS), homepage.

369. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
     April 18, 2004 - Advances in Patient Safety: Vol. 1 84 Table 1. … VISN 8 Patient Safety Center, Tampa, FL (AMS, RRC, CC, PP). … Suncoast Center for Patient Safety, Tampa, FL (AMS, RRC, JW). … Florida Patient Safety Center, Inc. (AMS, RRC). … Advances in Patient Safety: Vol. 1 98 48.

370. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
     January 01, 2004 - Advances in Patient Safety: Vol. 1 134 The methodology used to assess these occurrences utilized … The findings raised the issue about whether these facilities are more Advances in Patient Safety: … appeared as significant safety threats. … Sharing information among hospitals will facilitate learning about patient safety initiatives. … Making health care safer: a critical analysis of patient safety practices.

371. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
     March 01, 2002 - : Vol. 1 146 safety and the quality of hospital care. … Advances in Patient Safety: Vol. 1 154 T ab le 4 . … In: Beyond State reporting: Medical errors and patient safety issues. … Advances in Patient Safety: Vol. 1 160 51. Billings C. … A tale of two stories: contrasting views of patient safety.

372. Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/French.pdf
     April 27, 2004 - uses of information technology to improve medication safety in the outpatient setting. … Advances in Patient Safety: Vol. 1 196 Future studies will refine the episodes of care associated … VISN 8 Patient Safety Center (AMS, RRC, PP, DCW). VISN 8 Measurement Evaluation Team (DDF). … Advances in Patient Safety: Vol. 1 198 28. … Pharmacoepidemiology and Drug Safety 2004; In press. (Published online: April 27, 2004.) 49.

373. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Schillinger.pdf
     January 01, 2004 - Advances in Patient Safety: Vol. 1 200 Introduction For patients with atrial fibrillation and other … We Advances in Patient Safety: Vol. 1 202 obtained the clinicians’ regimen reports by recording … Advances in Patient Safety: Vol. 1 210 15. Golin CE, Smith SR, Reif S. … Medication safety: moving from illusion to reality. JAMA 2003 289(9):1154–6. 41. … Advances in Patient Safety: From Research to Implementation.

374. Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Masheter.pdf
     March 01, 2004 - AHRQ patient safety indicators AHRQ and Stanford University have developed 20 Patient Safety (PS) … Utah Patient Safety Updates. Vol. I, No. 1–5. … Utah/Missouri Patient Safety Project. … Patient safety sentinel event reporting. State of Utah. … Advances in Patient Safety: Vol. 1 244 21. U.S.

375. Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Campbell.pdf
     January 01, 2003 - Center for Patient Safety is a leader in this movement. … The VHA emphasizes a culture of safety and focuses its patient safety initiatives and reporting on systems … The VHA is a leader in patient safety research and intervention Advances in Patient Safety: Vol. … A national profile of patient safety in U.S. hospitals. … Patient Safety Committee. Patient safety efforts should focus on errors.

376. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
     March 01, 2004 - They are intended to flag patient safety problems and point to areas for investigation and intervention … Records were sampled using the following criteria: First, only Advances in Patient Safety: Vol. 1 … Patient Safety Indicators, Version 2.1, Revision 1. … Hougland P, Masheter C, Xu W, Utah/Missouri Patient Safety Consortium. … Patient safety efforts should focus on medical injuries. JAMA 2002;287(15):1993–7. 23.

377. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
     March 15, 2004 - Advances in Patient Safety: Vol. 1 276 The few studies that have used comparison groups have focused … Initial Cases Advances in Patient Safety: Vol. 1 278 surgical occurrences for an elderly population … Advances in Patient Safety: Vol. 1 284 Table 3. … It may be valuable to target peripheral vascular bypass and colorectal resection in patient safety … Advances in Patient Safety: Vol. 1 288 Funding for this project came from the Centers for Medicare

378. Can We Talk? Priorities for Patient Care Differed Among Health Care Providers (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Evanoff.pdf
     January 01, 2003 - Efforts to improve health care safety and quality are dependent on teamwork and are jeopardized by the … Advances in Patient Safety: Vol. 1 8 Results Reported communication between health care providers … There was Advances in Patient Safety: Vol. 1 10 Table 3. … Advances in Patient Safety: Vol. 1 14 19. Fuss MA, Bryan YE, Hitchings KS, et al. … Anaesthetists’ attitudes to teamwork and safety. Anaesthesia 2003;58(3):233–42. 22.

379. Prologue—Volume 1—Five Years Later—Are We Any Safer? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
     January 01, 2004 - on the execution of patient safety efforts, and catalogued four major barriers at that level: 1. … Advances in Patient Safety: Vol. 1 2 4. … Patient safety represents a difficult and complex problem. Dr. … We all hold the future of patient safety in our hands. … Patient safety proves elusive. Mod Healthc 2004 Nov 1;pp. 6–7, 24–5, 30, 32. 4. Blendon RJ.

380. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
     January 01, 2003 - nurse education, and hospital procedures have been identified as important risk factors for patient safety … The study of proximate causes of errors and other sudden-onset events may be Advances in Patient Safety … Advances in Patient Safety: Vol. 1 56 Table 1. … Additionally, we restricted our enrollment criteria to Advances in Patient Safety: Vol. 1 62 … Advances in Patient Safety: Vol. 1 64 23. Potter P, Barr N, McSweeney M, et al.