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7041. 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.

7042. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schillinger.pdf
      January 01, 2004 - Advances in Patient Safety: Vol. 2 200 Drugs, such as oral anticoagulants, that have a narrow therapeutic … Advances in Patient Safety: Vol. 2 202 We obtained patients’ indications for chronic anticoagulation … Advances in Patient Safety: Vol. 2 210 Acknowledgments This research was supported through grants … Medication safety: moving from illusion to reality. JAMA 2003;289(9):1154–6. 33. … Advances in Patient Safety: Vol. 2 212 46. Smedley BD, Stith AY, Nelson AR.

7043. Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Chan.pdf
      July 01, 2004 - Medication safety research Collectively, the datasets have been referred to as the first Patient Safety … research as well as non-Patient Safety research. … Advances in Patient Safety: Vol. 2 236 Table 5. … Advances in Patient Safety: Vol. 2 238 References 1. … Data elements in the HMO Research Network Patient Safety dataset Table 3.

7044. Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Devine.pdf
      July 01, 2003 - Introduction During the millennium period, the issue of patient safety was elevated to national focus … An integral part of this value system is the promotion of a culture of safety. … These two committees oversee the patient safety aspects of the ACPOE implementation. … National observational study of prescription dispensing accuracy and safety in 50 pharmacies. … Advances in Patient Safety: Vol. 2 198 19.

7045. Barriers Associated with Medication Information Handoffs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
      January 01, 2004 - Making health care safer: a critical analysis of patient safety practices. … Making health care safer: a critical analysis of patient safety practices. … AHRQ’s patient safety initiative. Building foundations, reducing risk. … safety/npsg.htm. … Technology and safety: a two- edged sword.

7046. Implementation of a Data-based Medical Event Reporting System 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/vol3/Davis.pdf
      February 12, 2004 - The system has helped to identify patterns of patient safety errors and areas where patient safety events … patient safety newsletters (available on the DoD patient safety Web site), patient safety hot topic … Center MHSPSR: Military Health System Patient Safety Registry Advances in Patient Safety: Vol. … Center PSO/M: Patient Safety Officer /Manager PSR: Patient Safety Registry PSWG: Department of … Defense Patient Safety Work Group QuIC: Quality Interagency Coordination Task Force SAC: Safety

7047. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
      January 01, 2005 - From this frame large, medium, Advances in Patient Safety: Vol. 3 226 and small facilities as … Some facilities also ask to include quality managers or patient safety managers. … sites, and for MedSun authorized reporters.5 FDA Patient Safety News. … Device Safety Exchange (DS-X). … It also is vital to provide useful feedback so patient safety may be improved.

7048. From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Kravitz.pdf
      February 09, 2005 - White Abstract Clinical decision support (CDS) systems show promise for enhancing patient safety, … If “all politics is local,” then much of patient safety research is localized as well. … Advances in Patient Safety: Vol. 3 406 Table 2. … Improving safety with information technology. N Engl J Med 2003;348(25): 2526–34. 3. … Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.

7049. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Anthony.pdf
      January 01, 2005 - Advances in Patient Safety: Vol. 2 386 Figure 4. … Advances in Patient Safety: Vol. 2 390 mistake and potential consequences of the error. … A presentation at the national Summit on medical errors and patient safety research. … http://www.jcaho.org/accredited+organizations/patient +safety/npsg.htm. 7. … Advances in Patient Safety: Vol. 2 394 36. Frankel RM, Devers K.

7050. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
      January 01, 2003 - A total of 16 Advances in Patient Safety: Vol. 2 398 Figure 1. … Reliab Eng and Syst Safety 1998;59:187–99. 14. Brown A, Haugene B. … Reliability Eng and Syst Safety 1994;45:139–57. 16. Linnerooth-Bayer J, Wahlstrom B. … Comprehensive patient safety programs in health care settings. … Statewide patient safety coalitions: a status report.

7051. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flink.pdf
      April 09, 2004 - Advances in Patient Safety: Vol. 3 140 Table 2. … Patient Safety Conference The NYSDOH will hold a statewide Patient Safety Conference to disseminate … Patient safety: achieving a new standard of care. … /safety/iom_response3.php. 11. … Patient Safety Reporting System.

7052. Cost Effectiveness of a Multifaceted Program for Safe Patient Handling (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Siddharthan.pdf
      January 10, 2005 - Introduction The National Institute for Occupational Safety and Health identifies back injury as the … Author affiliations Patient Safety Center of Inquiry, James A. … Address correspondence to: Kris Siddharthan, Ph.D., Patient Safety Center, James A. … Veterans Administration, Office of Occupational Safety and Health. … Advances in Patient Safety: Vol. 3 358 16. Berk A, Paringer L, Mushkin SJ.

7053. Clinical Inertia and Outpatient Medical Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
      January 01, 2003 - or misuse of therapies, and adverse events attributable to clinical inertia Advances in Patient Safety … Advances in Patient Safety: Vol. 2 296 Prevalence and cost of clinical inertia Prevalence It … Advances in Patient Safety: Vol. 2 302 The recommended visit interval of 3–6 months for those with … Advances in Patient Safety: Vol. 2 308 47. Pellegrini F, Belfiglio M, De Berardis G, et al. … Advances in patient safety: from research to implementation.

7054. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
      January 01, 2004 - The impact of diagnostic failure on patient safety does not appear to have been fully recognized. … Advances in Patient Safety: Vol. 2 244 The word “bias” originally was used in the game of bowls to … Advances in Patient Safety: Vol. 2 246 Impact of affective state Physicians and caregivers are … Advances in Patient Safety: Vol. 2 254 38. Poses RM, Cebul RD, Collins M, et al. … Safety errors in emergency medicine. In: Markovchick VJ, Pons PT, editors.

7055. Identifying Barriers to the Success of a Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harper.pdf
      March 01, 2004 - A team of researchers at the University of Texas Center of Excellence for Patient Safety Research and … (See Table 2 for a list Advances in Patient Safety: Vol. 3 174 Table 2. … To err is human: building a safety health system. … The Patient Safety Reporting System. … Aviation safety reporting program. Federal Aviation Administration, Advisory Circular 00-46B.

7056. 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.

7057. 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.

7058. Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Schiff.pdf
      January 01, 2005 - Advances in Patient Safety: Vol. 2 264 Figure 1. … Advances in Patient Safety: Vol. 2 272 T ab le 4 . … How the public perceives patient safety. … Administrative data based patient safety research: a critical review. … Advances in Patient Safety: Vol. 2 278 82. McDonald J.

7059. 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.

7060. Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Daudelin.pdf
      January 01, 2000 - Selker Abstract Information Technology (IT) solutions to patient safety/medical error problems are … Many current IT applications for patient safety are focused on hospital processes, such as physician … Advances in Patient Safety: Vol. 3 8 Introduction Acute coronary syndrome (ACS) and the synonymous … Advances in Patient Safety: Vol. 3 14 Figure 5. … for quickly compiling data into one system for use in a patient safety system.