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461. Role of the External Coach in Advancing Research Translation in Hospital-Based Performance Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Donaldson_87.pdf
     April 23, 2008 - Consistently implemented 19 64 A guide to reevaluation of fall risk 55 57 Inclusive of sitters/safety

462. Department of Veterans Affairs Emergency Airway Management Initiative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Stalhandske_71.pdf
     February 23, 2008 - However, the VA’s National Center for Patient Safety identified some cases in which clinicians attempted … The survey was sent by e-mail to patient safety managers at all 163 VA hospitals in September 2002. … Department of Veterans Affairs identified a significant issue through their patient safety program: … 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

463. The Rural Physician Peer Review Model©: A Virtual Solution (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Williams_115.pdf
     June 19, 2008 - technology to share HIPAA-compliant information, a systems approach to review, principles of patient safety … including a network of hospitals as its base, with a central staff, a quality improvement/patient safety … Approach of Quality Improvement/Patient Safety RCHI leaders searched for ways to implement the hallmarks … of the perspective of patient safety and quality improvement. … Patient safety issues, Joint Commission requirements, and other regulatory mandates are discussed as

464. Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hueckel_27.pdf
     April 01, 2008 - Because of growing interest in these systems, experts in the field of patient safety and critical-care … identified patient need with triage, direct patient care, or escalation of patient monitoring.2 Patient safety … Therefore, to improve patient safety, we attempted to proactively survey care providers on the wards … The PRRT and Rover Teams contributed to an environment of patient safety. C. … Rover component and a Reactive Response Team was found to contribute to an environment of patient safety

465. Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Gandhi_22.pdf
     February 01, 2007 - MD, MS Abstract Objectives: Poor outpatient referral communication is an important quality and safety

466. News Media and Health Care Providers at the Crossroads of Medical Adverse Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Whitten_85.pdf
     June 05, 2008 - Although the mandate was designed to improve patient safety, the long-term success of mandatory reporting … system, which allows between 44,000 and 98,000 medical errors per year, is a necessity for patient safety … The overarching theme propelling this mandatory change is patient safety. … Patient safety toolbox for states. Portland, ME: National Academy State Health Policy. … Patient safety and medical adverse event: A roadmap for state action. Portland, ME.

467. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
     March 03, 2008 - Standard safety interventions for all patients admitted to the hospital Environmental safety 1. … Patient safety 1. … safety, patient safety, and daily routines (Table 2). … Unit-Specific Safety Model The project team developed a unit-specific safety model based on the notion … safety in the “Bathroom.”

468. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of 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-Shah_99.pdf
     March 23, 2008 - Sections were developed and ordered based on a review of patient safety literature. … Clinical oversight: Conceptualizing the relationship between supervision and safety. … The incorporation of patient safety into board certification examinations. … Promoting patient safety and preventing medical error in emergency departments. … id=5882 Appendix: EM Trainee Patient Safety Questionnaire PATIENT SAFETY QUESTIONNAIRE DEFINITION

469. The Impact of Standardized Order Sets on Quality and Financial Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ballard_12.pdf
     February 02, 2008 - testing, the order set is reviewed by the BHCS Pharmacy and Therapeutics Committee and the Patient Safety … Changes are reviewed by the BHCS Pharmacy and Therapeutics and Patient Safety Committees. … APR DRG Risk of Mortality was used in the models for safety and effectiveness indicators, while APR … hospitals that used vs. did not use the order set: March 1, 2006 - September 30, 2007 Order set Safety … hospitals: March 1, 2006-September 30, 2007 Outcome Covariate adjusteda Propensity score adjustedb Safety

470. Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute 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-Hook_25.pdf
     February 26, 2008 - , safety management, injury control, safety promotion, and accident prevention, to name a few. … Joint Commission. 2008 National patient safety goals: Hospital program. … National Center on Patient Safety toolkit: Falls policy. … Making health care safer: A critical analysis of patient safety practices. … Safety. In: Lueckenotte AG, ed. Gerontologic nursing. 2nd ed. St.

471. Common Cause Analysis: Focus on Institutional Change (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Browne_5.pdf
     January 20, 2008 - acting alone, predominates in establishing safety. … Department of Veterans Affairs National Center for Patient Safety (NCPS). … Michael Cohen on medication error reporting and patient safety. … VA National Center for Patient Safety; 2007. … Using aggregate root cause analysis to improve patient safety.

472. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Riley_58.pdf
     April 02, 2008 - Patient safety: Achieving a new standard for care. … Medical teamwork and patient safety: The evidence-based relations. … Promoting health care safety through training high reliability teams. … Safety Sci 2003; 41: 409-425. 30. Thomas EJ, Sexton JB, Helmreich RL. … Video capture of clinical care to enhance patient safety.

473. Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-David_13.pdf
     March 19, 2008 - the efficiency and safety of this process. … is proactively focused on safety promotion vs. … Medication safety in the ambulatory chemotherapy setting. Cancer 2005; 104: 2478-2483. 9. … ISMP Medication Safety Self Assessment® for Hospitals. … Medication safety in critically ill children. Clin Ped Emerg Med 2006; 7: 215-225. 22.

474. Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Hagg_80.pdf
     January 01, 2007 - Quality improvement (QI) initiatives within health care facilities are often designed to improve the safety … Quality improvement implementation and hospital performance on patient safety indicators. … Patient safety proves elusive. … The business case for patient safety. Clin Orthop Relat Res 2007; 457: 21-34. 14. … What do we know about financial returns on investments in patient safety? A literature review.

475. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Deis_82.pdf
     June 03, 2008 - In an effort to promote patient safety at our institution, we implemented a monthly interdisciplinary … that the purpose of the discussion is to assign blame for an error rather than to improve patient safety … In an effort to promote patient safety at our institution, we implemented a monthly hospital-wide morbidity … Children’s Hospital at Vanderbilt to improving patient care and safety. … these process changes have not yet been rigorously evaluated to determine their effects on patient safety

476. High-Hanging Fruit: Improving Transitions 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/vol3/Advances-Perry_49.pdf
     March 27, 2008 - Wears); Clinical Safety Research Unit, Imperial College London, London, UK (Dr. … Healthcare systems, ergonomics and patient safety. … Prepared for Health and Safety Executive, Offshore Safety Division. … Transitions in care: Studying safety in emergency department signovers. … Closing the communication loop: Using readback/hearback to support patient safety.

477. Minding the Gaps: Creating Resilience 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/vol3/Advances-Nemeth_116.pdf
     April 27, 2008 - popular notions about how to improve safety and performance in health care. … System-Level Safety No system has infinite adaptive capacity. … Gaps in the continuity of care and progress on patient safety. … Systemic safety assessment of production installations. … Safety and efficacy of target controlled infusion (diprifusor) vs.

478. Error Producing Conditions in the Intensive Care Unit (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_15.pdf
     February 26, 2008 - designed to reduce the device-related potential for patient harm should be a primary goal in patient safety … This is an important step toward the goal of reducing hazards and improving patient safety. … Quality and safety in the intensive care unit. J Intensive Care Med 2006; 21: 199-210. 9. … Patient safety: Improving safety with information technology. … In: Advances in Patient Safety: New Directions and Alternative Approaches.

479. Using Data Mining to Predict Errors in Chronic Disease Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-McCabe_39.pdf
     March 28, 2008 - technologies to predict treatment errors in populations of patients represents a major advance in patient safety … Advances in patient safety: From research to implementation. Vol 1: Research findings. … Advances in patient safety: From research to implementation.

480. The Impact of Health Information Technology on Work Process and Patient Care in Labor and Delivery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Campbell_47.pdf
     March 11, 2008 - Objective: Implementation of health information technology (HIT) is a national priority to improve patient safety … Introduction In 1999, the Institute of Medicine (IOM) brought the world’s attention to the patient safety … to be widely implemented in the United States,3 but data on the impact of these systems on patient safety … area noted to be lagging behind other specialties in EHR adoption.31 The aim of the larger patient safety … is to systematically evaluate the value of incremental advancements in HIT integration for patient safety