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381. An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Potter.pdf
     January 01, 2003 - Healthcare Research and Quality has made the effects of health care working conditions on patient safety … date, human factors research aimed at understanding the effects of working conditions on patient safety … Advances in Patient Safety: Vol. 1 46 Table 1. … Certainly understaffing is a threat to patient safety. … The effect of health care working conditions on patient safety.

382. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)
     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 - These inconsistencies represented a patient safety threat in the form of nosocomial infections, prolonged … : Vol. 3 522 improvement of safety for patients. … Advances in Patient Safety: Vol. 3 524 Table 2. … Each unit was Advances in Patient Safety: Vol. 3 526 contacted and its staff members received … Conclusion Patient safety is expected to be the highest priority for health care providers.

383. Physician Use of Hand-held Computers for Drug Information and Prescribing (pdf file)
     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 - similar purposes.4 Many respected, credible, electronic information sources Advances in Patient Safety … Advances in Patient Safety: Vol. 4 98 Construction of the instrument The survey instrument covered … Advances in Patient Safety: Vol. 4 100 Path analysis Path analysis was conducted using a stepwise … Advances in Patient Safety: Vol. 4 108 References 1. Overdyk FJ, Haynes GR, Arvanitis PJ. … Communication from Veterans Affairs Patient Safety Center, 2002. 23.

384. A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Arroyo.pdf
     June 11, 2003 - If needed, changes in policy or procedure are made to improve patient safety. … Ongoing training is provided to all staff on patient safety programs and requirements. … Advances in Patient Safety: Vol. 4 80 References 1. … Patient safety: achieving a new standard for care. … Patient safety: instilling hospitals with a culture of continuous improvement.

385. Background -- AHRQ and other funders interest in promoting faster movement from research to practice/science to service/TRIP/T (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carpenter.pdf
     January 01, 2004 - Deborah Carpenter, Veronica Nieva, Tarek Albaghal, Joann Sorra Abstract Investigation in patient safety … These grants and contracts were collectively named the AHRQ Patient Safety Portfolio. … Advances in Patient Safety: Vol. 4 whose members represent patient safety grantees across the … Patient safety researchers within the Patient Safety Portfolio also were recruited to complete the draft … In: Advances in patient safety: from research to implementation.

386. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     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 - There have been several calls for medical schools and academic medical centers to improve patient safety … from medical errors.1 Following the IOM report, there have been numerous calls to improve patient safety … Advances in Patient Safety: Vol. 4 360 Author affiliations UCLA Center for Patient Safety and Quality … Innovative training for enhancing patient safety. Safety culture and integrated concepts. … Understanding medical error and improving patient safety in the inpatient setting.

387. Development of a Screening Tool for Safe Wheelchair Seating (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
     January 01, 2001 - home residents who use wheelchairs for mobility need some type of seating Advances in Patient Safety … Advances in Patient Safety: Vol. 4 130 Expert rating. … Advances in Patient Safety: Vol. 4 132 Table 2. … Haley VA Medical Center, Patient Safety Center of Inquiry, Tampa (DG, AN, SL). … Haley VA Hospital, Patient Safety Center of Inquiry, 11605 N.

388. Developing a Taxonomy of Anesthetists’ Nontechnical Skills (ANTS) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
     January 01, 2004 - Skills (ANTS) Rona Patey, Rhona Flin, Georgina Fletcher, Nicola Maran, Ronnie Glavin Abstract Safety … National Patient Safety Agency, London, U.K. (GF). … Crew resource management: improving safety in high reliability industries. … Advances in Patient Safety: Vol. 4 336 7. Maran N, Glavin R, Fletcher G. … Anaesthetists’ attitudes to teamwork and safety. Anaesthesia 2003;58:233–42. 14. Jordan P.

389. The Use of Surgical Simulators to Reduce Errors (pdf file)
     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 - Advances in Patient Safety: Vol. 4 166 Introduction The emphasis on patient safety in the operating … Given that competence and safety are of paramount importance, the objective measure of a resident’s … Simulation has the potential to improve patient safety and reduce surgical errors by screening would-be … Metrics How can surgical safety be measured appropriately? … Advances in Patient Safety: Vol. 4 176 References 1. Dawson SL.

390. SimCare: A Model for Studying Physician Decisionmaking Activity (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Dutta.pdf
     January 01, 2003 - Some of the major cognitive tasks include— Advances in Patient Safety: Vol. 4 180 • Selecting … Physician interaction with SimCare Advances in Patient Safety: Vol. 4 182 displayed in formats … Structured walk-throughs were performed Advances in Patient Safety: Vol. 4 188 with an expert … Advances in Patient Safety: Vol. 4 190 stimulating hormone was made 327 seconds into the case. … Advances in patient safety: from research to implementation. Vol. 1, Research findings.

391. Standardizing Medication Error Event Reporting 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/vol4/Nosek.pdf
     March 01, 2004 - Pharmacopeia, Center for Advancement in Patient Safety. … safety officers and is intended to address patient safety issues identified in event reports or derived … from other reputable patient safety resources. … organizations, and the Patient Safety Center Registry. … In response to the perceived safety threat, the PSC released its first DoD Patient Safety Alert in

392. Best Practices for Medical Technology Management: A U.S. Air Force–ECRI Collaboration (pdf file)
     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 - : Vol. 4 52 related to these potential safety threats. … integrity, and overall device quality and safety. … safety goal in 2003, along with five other goals. … Similarly, JCAHO has announced patient safety goals for 2005. … to JCAHO’s alarm safety goal.

393. Medical Team Training Programs in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Baker.pdf
     February 01, 2005 - In: Making health care safer: A critical analysis of patient safety practices. … Medical teamwork and patient safety: the evidence-based relation. … Patient Safety Initiative 2000—Spotlighting Strategies, Sharing Solutions. … In: enhancing patient safety and reducing errors in health care. … Medical team management: improving patient safety through human factors training.

394. Creating a Curriculum for Training Health Profession Faculty Leaders (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Mitchell.pdf
     March 31, 2004 - Eisenberg Patient Safety Award for systems innovation. … learning and patient safety into their home curriculum. … Eisenberg Patient Safety Awards. System innovation: Concord Hospital. … Advances in Patient Safety: Vol. 4 312 38. Gosbee J. … Eisenberg Patient Safety Awards.

395. Combining Performance Feedback and Evidence-based Educational Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meurer.pdf
     January 01, 2004 - , and evaluation of effective practices in patient safety. … Advances in Patient Safety: Vol. 4 240 Figure 1. … Advances in Patient Safety: Vol. 4 244 T ab le 1 . … Data alone may be insufficient to drive hospital safety efforts. … Patient safety: achieving a new standard of care.

396. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
     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 - Jones, Shulamit Bernard Abstract Objective: In this era of patient safety, quality indicators associated … Health and safety survey 2001. http://nursingworld.org/surveys/ hssurvey.pdf. … The role of theory in improving patient safety and quality health care. … Measures of patient safety based on hospital administrative data— the patient safety indicators. … Comparison of relevant AHRQ, ANA, and NQF patient safety measures Figure 1.

397. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
     January 01, 2003 - : Vol. 4 194 typical patient safety challenges. … Advances in Patient Safety: Vol. 4 198 Table 1. … Patient safety: understanding and responding to adverse events. … A tale of two stories: contrasting views of patient safety. … Chicago: National Patient Safety Foundation; 1998. 19.

398. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - morbidity and mortality conferences, five cases are posted each month to illustrate diverse patient safety … equally between providers (half nurses and half physicians) and nonproviders with an interest in safety … Similar response rates were tallied for questions regarding practical value, patient safety content, … Balance between patient safety lessons and desire to recruit a nonexpert readership. … Recruit a broad audience interested, but not expert, in patient safety.

399. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - Despite this, medication-related problems that jeopardize patient safety are common in nursing homes … Table 1 highlights the RAPs targeted as part of the current patient safety research project, as well … We did so because we believed that falls and delirium pose the largest threats to patient safety in … The Falls Medication Monitoring Care Plan Advances in Patient Safety: Vol. 4 410 Figure 3. … GRAM™ software focus of patient safety study in nursing facilities.

400. Background -- AHRQ and other funders interest in promoting faster movement from research to practice/science to service/TRIP/T (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carpenter.doc
     January 01, 2004 - promoting faster movement from research to practice/science to service/TRIP/T Advances in Patient Safety … These grants and contracts were collectively named the AHRQ Patient Safety Portfolio. … represent patient safety grantees across the portfolio. … Patient safety researchers within the Patient Safety Portfolio also were recruited to complete the draft … In: Advances in patient safety: from research to implementation.