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421. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Preface.pdf
     February 01, 2005 - Although we have made improvements in the safety of the health care system since that time, there is … The publication included work by AHRQ-funded patient safety researchers as well as the patient safety … This new publication, Advances in Patient Safety: New Directions and Alternative Approaches builds on … and expands the growing body of evidence for reducing medical errors and improving patient safety. … They continue to seek answers to the most challenging patient safety questions.

422. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Preface.pdf
     February 01, 2005 - Although we have made improvements in the safety of the health care system since that time, there is … The publication included work by AHRQ-funded patient safety researchers as well as the patient safety … This new publication, Advances in Patient Safety: New Directions and Alternative Approaches builds on … and expands the growing body of evidence for reducing medical errors and improving patient safety. … They continue to seek answers to the most challenging patient safety questions.

423. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Preface.pdf
     February 01, 2005 - Although we have made improvements in the safety of the health care system since that time, there is … The publication included work by AHRQ-funded patient safety researchers as well as the patient safety … This new publication, Advances in Patient Safety: New Directions and Alternative Approaches builds on … and expands the growing body of evidence for reducing medical errors and improving patient safety. … They continue to seek answers to the most challenging patient safety questions.

424. Preface (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Preface.pdf
     February 01, 2005 - Although we have made improvements in the safety of the health care system since that time, there is … The publication included work by AHRQ-funded patient safety researchers as well as the patient safety … This new publication, Advances in Patient Safety: New Directions and Alternative Approaches builds on … and expands the growing body of evidence for reducing medical errors and improving patient safety. … They continue to seek answers to the most challenging patient safety questions.

425. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/reporting/index.html
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426. Index
     www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-hai/index.html
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427. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - Improving patient safety is a key initiative across the system, as safety is the basis upon which all … An HRO has an exceptional safety record, not merely above average. … Staff see PEERs as an opportunity to share issues not related to patient safety. … PEERs reports also have driven patient safety in the obstetrics department. … Developing a culture of safety in the Veteran’s Health Administration.

428. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
     January 01, 2007 - We monitor safety event reporting and provide concise, action-oriented feedback through quarterly composite … The overall goal of the cooperative agreement was the improvement of patient safety by implementation … and use of a statewide voluntary patient safety reporting system. … We present the results of analysis of reported hospital safety events over the first nine quarters of … Promoting patient safety by preventing medical error. JAMA 1998; 280:1444-1447. 11.

429. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - • Identification of needs for safety improvement. … A tale of two stories: Contrasting views of patient safety. … Geneva, Switzerland: World Alliance for Patient Safety; 2005. 6. … Patient safety: Achieving a new standard for care. … Beyond Babel: Prospects for a universal patient safety taxonomy.

430. 26,000 Close Call Reports: Lessons from 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-2/vol1/Advances-Simmons_66.pdf
     April 03, 2008 - Safety” Management Award. … Plans to recognize patient safety champions with safety award certificates and “Most Valuable Player … and proactive intervention for safety.10 Close calls—or Figure 2. … Patient safety: Achieving a new standard of care. … Sensemaking of patient safety risks and hazards.

431. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
     January 01, 2007 - The value of educating physicians, house staff, and medical students about patient safety cannot be … of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Center for Patient Safety … Disruptive behavior in obstetrics: A hidden threat to patient safety. … Physician perception of hospital safety and barriers to incident reporting.

432. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
     July 17, 2008 - MEDMARX is a potential data source for patient safety organizations (PSO). … Structure and Process as Determinants of Medication Safety Analyses from large patient safety databases … The patient safety and quality improvement act of 2005. … Rockville, MD: USP Center for the Advancement of Patient Safety; 2006. 23. Cohen MR. … Organizations in Medication Safety Structure and Process as Determinants of Medication Safety Methods

433. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
     January 01, 2021 - First do no harm: Executive briefing on medication safety.

434. Relationship Between Patient Harm and Reported Medical Errors in Primary Care: 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-2/vol1/Advances-West_102.pdf
     March 31, 2008 - Introduction Patient safety reporting systems (PSRS) are useful tools to understand the scope of errors … ASIPS Patient Safety Reporting System The core of the ASIPS PSRS is a Web-based data collection and … The challenge is to determine how to best use these data to improve patient safety. … Advances in patient safety: From research to implementation. Vol. 3, Implementation issues. … Patient safety: Achieving a new standard for care.

435. Improving Error Reporting in Ambulatory Pediatrics with a Team Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Neuspiel_43.pdf
     March 05, 2008 - All reports were reviewed monthly by the pediatric safety champion team, which conducted root- cause … Errors were classified by the safety team as primarily involving office administration (34 percent), … Patient safety in the ambulatory setting: A clinician- based approach. … Ambulatory patient safety. What we know and need to know. … In: Advances in Patient safety: From research to implementation.

436. Development of a Comprehensive Medical Error Ontology (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Mokkarala_103.pdf
     June 16, 2008 - most of the existing classification schemes may be well suited to the particular clinical setting or safety … clear that the lack of a framework and agreement about how to define and classify adverse patient safety … data analysis and for learning from errors and to promote development of interventions for patient safety … MEDWATCH - The FDA Safety Information and Adverse Event Reporting Program. … Doing what counts for patient safety: Federal actions to reduce medical errors and their impact.

437. A System to Describe and Reduce Medical Errors in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kaprielian_9.pdf
     January 01, 2007 - Introduction Efforts to increase patient safety within hospital settings are numerous and have resulted … can be collected in a real-life clinical setting and used to reduce errors and build a culture of safety … errors in primary care is the question of how small- and medium-sized practices can develop patient safety … When developing patient safety reporting systems, providers should take care to learn from successful … Medical teamwork and patient safety: The evidence-based relation.

438. Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gururaja_7.pdf
     January 24, 2008 - TeamSTEPPS™: Strategies and tools to enhance performance and patient safety. … Sample outline for a patient safety plan. Available at: www.ahrq.gov/qual/teamstepps. … Medical teamwork and patient safety: The evidence-based relation. Literature review. … Advances in patient safety: New directions and alternative approaches. … In Anca Jr JM, ed., Multimodal safety management and human factors.

439. Effect of Recent Refresher Training on in Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Nishisaki_44.pdf
     April 19, 2008 - Medical simulation has been recognized as an effective tool to improve patient safety. … The role of simulation in patient safety. In: Dunn WF, eds. … Does simulation improve patient safety? … Self-efficacy, competence, operational performance, and patient safety. … Improving patient safety through simulation research.

440. Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
     April 07, 2008 - Joint Comisssion perspectives on patient safety. Using FMEA to assess risk and reduce error. … Advances in patient safety: From research to implementation. … Third Conference on Safety Across High-Consequence Industries; 2007 Mar 13-15; St. … Organizing patient safety research to identify risks and hazards. … Sensemaking of patient safety risks and hazards.