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441. Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Jack_28.pdf
     February 21, 2008 - These flaws are magnified in safety net hospitals, like Boston Medical Center, where the connection … A full description of this process was published in the AHRQ publication, Advances in Patient Safety … Patient safety at time of discharge: An example of a multifaceted process evaluation. … AHRQ Advances in Patient Safety Vol 2. … Patient safety concerns arising from test results that return after hospital discharge.

442. Patient Monitors in Critical Care: Lessons for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_16.pdf
     January 01, 2003 - These efforts have yielded marked improvements in the safety and efficiency of airplane and nuclear … domains to health care in general and patient monitoring in particular will lead to improved patient safety … Designing for transportation safety in the light of perception, attention, and mental models. … Handbook of human factors and ergonomics in healthcare and patient safety.

443. Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
     March 07, 2008 - The features of such a clinic would also improve the culture of safety within the community, reduce … Creation of a health care culture of safety; and Item 18. … to Kirkwood Community College and Physicians’ Clinic of Iowa, Partnership for Implementing Patient Safety

444. Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Borowitz_4.pdf
     January 22, 2008 - arise during the next shift. 1 Effective and accurate sign-out is important for patient safety … ’s current state and his or her plan of care.8 This transfer of information is crucial for patient safety … Transitions in care: Studying safety in emergency department signovers. … Patient safety practices related to patient safety goal 2E. … British Medical Association, National Patient Safety Agency, NHS Modernisation Agency, Safe Handover

445. Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Kind_31.pdf
     March 31, 2008 - Despite the critical importance of discharge summaries in care transitions and patient safety, no studies … small frequency of omitted patient discharge condition information is a concern and may affect patient safety … care.1 High-quality discharge summaries are generally thought to be essential for promoting patient safety … Additionally, whether the Joint Commission standards are sufficient to maximize patient safety during … Patient safety concerns arising from test results that return after hospital discharge.

446. Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Harney_89.pdf
     May 01, 2007 - information is focused on the treatment of thrombosis rather than prevention.7 Despite the fact that the safety … On review of data obtained from the CHB Safety Events Reporting System, adverse event rates in FY 2005 … Limitations This descriptive paper cannot provide definitive evidence for improved safety; that will … effectiveness of interventions introduced by the service to standardize practice and improve patient safety

447. VHA’s National Falls Collaborative and Prevention Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Stalhandske2_70.pdf
     March 01, 2006 - This article presents three successful patient safety fall prevention projects completed within the … Author Affiliations VHA National Center for Patient Safety, Ann Arbor, MI. … Stalhandske, MPP, MHSA, VHA National Center for Patient Safety, 24 Frank Lloyd Wright Drive, Lobby M … VA Patient Safety Event Registry: First Nineteen Months of Reported Cases Summary and Analysis. … Department of Veterans Affairs, Veterans Health Administration National Center for Patient Safety.

448. Hospital Language Services: Quality Improvement and Performance Measures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Regenstein_54.pdf
     May 08, 2008 - interpreters can bridge the communication gap between provider and patient. 14 In the context of patient safety … First, we used the Institute of Medicine’s (IOM’s) six dimensions of quality (i.e., safety, timeliness … Applying IOM’s six domains of quality to language services • Safety: Avoiding injuries to patients … benefited from an enormously supportive cadre of forward-thinking chief executives who well understood the safety … build effective language services programs, health care organizations can improve quality and patient safety

449. In Situ Simulation: Challenges and Results (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Patterson_48.pdf
     May 05, 2008 - physically integrated into the clinical environment, provides a method to improve reliability and safety … In order to determine the safety of a particular vehicle, the National Highway Traffic Safety Administration … patient safety investigation. … • Safety from the life-threatening side effects of sedatives and pain medications. … Designing patient safety into the microsystem.

450. Measuring IT Sophistication in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Alexander_10.pdf
     January 20, 2008 - IT development has the potential to improve the safety, quality, and efficiency of health care in the … United States.9 Increasing attention to errors in health care and concern for patient safety have prompted … sophisticated IT lies in its ability to transform and achieve certain foundational aims, including safety … Improving safety with information technology. N Engl J Med 2003; 348: 2526-2534. 28.

451. Efficiency Gains with Computerized Provider Order Entry (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
     March 18, 2008 - It also supports the effort to improve quality of patient care and patient safety. … In order to improve both quality of care and patient safety, health care systems are implementing CPOE … Efficiencies of the system support better patient safety and quality of care. … Eisenberg patient safety awards. … The Leapfrog Group for Patient Safety: rewarding higher standards, J Comm J Qual Saf 2003; 29: 634-

452. Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Lynch_37.pdf
     March 21, 2008 - Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study John Lynch, MPH; Jonathan Rosen, MD; H. Andrew Selinger, MD; John Hickner, MD, MSc Abstract Objective: The objective of this study wa…

453. Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
     March 12, 2008 - machines (ADM) are a computerized companion technology that reduces labor and contributes to patient safety … This study highlighted an opportunity to embed the culture of patient safety to promote safe medication … and fostering a culture of patient safety. eMAR and barcoding represent the use of technology to prevent … Barcode medication and patient armband scan rates were evaluated for compliance with patient safety … This study highlighted an opportunity to embed the culture of patient safety.

454. Developing a Community-Wide Electronic Shared Medication List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Stock_113.pdf
     June 15, 2005 - care setting are critical to improving patient safety. … The PeaceHealth ambulatory medication safety culture survey. … Safety culture assessment: A tool for improving patient safety in healthcare organizations. … Psychometric analysis of the Hospital Survey on Patient Safety. … The safety climate survey: Psychometric and benchmarking properties.

455. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - , and medication safety technology. … IV infusion safety systems provide rapid, effective, and cost-effective patient safety improvement. … at the point of care, our culture of safety and team approach, and the IV infusion safety system’s … ISMP medication safety alert! Safety issues with patient-controlled analgesia. … ISMP medication safety alert!

456. Clinical Pharmacists in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-fairbanks_20.pdf
     February 21, 2008 - A qualitative study to derive an EPh role optimized for patient safety is also described. … in patient safety). The framework approach involves five major steps. … The staff also perceived that the EPh improved patient safety and quality of care. … Promoting patient safety and preventing medical error in emergency departments. … A critical analysis of patient safety practices. AHRQ Pub. No. 01-E058.

457. Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Masica_112.pdf
     November 30, 2010 - Additional safety outcomes include measures of MTM process and delivery. … These safety outcomes will be compared among all three study arms. … • Construct an MTM intervention that promotes patient safety. … Study outcomes (Table 3) are all linked to patient safety. … Standardization as a mechanism to improve safety in health care.

458. Risk of Concurrent Use of Prescription Drugs with Herbal and Dietary Supplements in Ambulatory Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Graham_77.pdf
     March 05, 2008 - Most dietary supplements are unlicensed, and manufacturers are not required to demonstrate efficacy, safety … Phillips); Center for Patient Safety, Dana-Farber Cancer Institute, Boston, MA (Dr. … Weingart, MD, PhD, Center for Patient Safety, Dana-Farber Cancer Institute, 44 Binney St., Boston, MA

459. Using Home Visits to Understand Medication Errors in Children (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Walsh_74.pdf
     May 28, 2008 - potential to help understand home medication errors in order to develop interventions to improve the safety … Introduction Despite over 3,000 publications about medication safety over the last 5 years, there continue … Principles of patient safety in pediatrics. … National Patient Safety Goals, 2008. … Advances in patient safety: From research to implementation. Vol. 1, Research Findings.

460. Challenges to Real-Time Decision Support in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Fitzgerald_108.pdf
     January 01, 2007 - Future output, testing, and development of the TR & R Project are described Safety and Errors in Emergency … , electric power production, chemical manufacturing, and the military.4 Efforts to improve patient safety … Gaba DM Structural and organizational issues in patient safety: A comparison of health care to other … JAMIA 2007; 14: 141-145. 14 Abstract Introduction Safety and Errors in Emergency Medical Care