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9581. Learning from Errors in Ambulatory Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
      February 01, 2004 - Three members of the research team (one pediatrician and two patient safety researchers) independently … Prior patient safety studies in ambulatory and in-patient adult populations have demonstrated that … (Problem type: Communication) Advances in Patient Safety: Vol. 1 364 Table 5. … Pediatric patient safety in the ambulatory setting. Ambul Pediatr 2004;4:47–54. 8. … Patient safety problems in children’s medical care: a Critical Incident Analysis.

9582. Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/OConnor.pdf
      November 29, 2004 - related to drug-drug interactions, use of contraindicated drugs, or failure to obtain recommended safety … Advances in Patient Safety: Vol. 1 372 Automated pharmacy data was used to ascertain names, dates … Advances in Patient Safety: Vol. 1 374 Table 2. … Jt Comm J Qual Safety. 2004;30(1):15–24. 10. Dovey SM, Meyers DS, Phillips RL, Jr., et al. … Advances in Patient Safety: Vol. 1 380 16. O’Connor P, Rush W, Pronk N, et al.

9583. Quantitative and Qualitative Analysis of Medication Errors: The New York Experience (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf
      January 01, 2004 - Advances in Patient Safety: Vol. 1 134 The methodology used to assess these occurrences utilized … The findings raised the issue about whether these facilities are more Advances in Patient Safety: … appeared as significant safety threats. … Sharing information among hospitals will facilitate learning about patient safety initiatives. … Making health care safer: a critical analysis of patient safety practices.

9584. Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Desikan.pdf
      March 01, 2002 - : Vol. 1 146 safety and the quality of hospital care. … Advances in Patient Safety: Vol. 1 154 T ab le 4 . … In: Beyond State reporting: Medical errors and patient safety issues. … Advances in Patient Safety: Vol. 1 160 51. Billings C. … A tale of two stories: contrasting views of patient safety.

9585. Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/French.pdf
      April 27, 2004 - uses of information technology to improve medication safety in the outpatient setting. … Advances in Patient Safety: Vol. 1 196 Future studies will refine the episodes of care associated … VISN 8 Patient Safety Center (AMS, RRC, PP, DCW). VISN 8 Measurement Evaluation Team (DDF). … Advances in Patient Safety: Vol. 1 198 28. … Pharmacoepidemiology and Drug Safety 2004; In press. (Published online: April 27, 2004.) 49.

9586. Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Schillinger.pdf
      January 01, 2004 - Advances in Patient Safety: Vol. 1 200 Introduction For patients with atrial fibrillation and other … We Advances in Patient Safety: Vol. 1 202 obtained the clinicians’ regimen reports by recording … Advances in Patient Safety: Vol. 1 210 15. Golin CE, Smith SR, Reif S. … Medication safety: moving from illusion to reality. JAMA 2003 289(9):1154–6. 41. … Advances in Patient Safety: From Research to Implementation.

9587. Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Masheter.pdf
      March 01, 2004 - AHRQ patient safety indicators AHRQ and Stanford University have developed 20 Patient Safety (PS) … Utah Patient Safety Updates. Vol. I, No. 1–5. … Utah/Missouri Patient Safety Project. … Patient safety sentinel event reporting. State of Utah. … Advances in Patient Safety: Vol. 1 244 21. U.S.

9588. Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Campbell.pdf
      January 01, 2003 - Center for Patient Safety is a leader in this movement. … The VHA emphasizes a culture of safety and focuses its patient safety initiatives and reporting on systems … The VHA is a leader in patient safety research and intervention Advances in Patient Safety: Vol. … A national profile of patient safety in U.S. hospitals. … Patient Safety Committee. Patient safety efforts should focus on errors.

9589. Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Tuinen.pdf
      March 01, 2004 - They are intended to flag patient safety problems and point to areas for investigation and intervention … Records were sampled using the following criteria: First, only Advances in Patient Safety: Vol. 1 … Patient Safety Indicators, Version 2.1, Revision 1. … Hougland P, Masheter C, Xu W, Utah/Missouri Patient Safety Consortium. … Patient safety efforts should focus on medical injuries. JAMA 2002;287(15):1993–7. 23.

9590. Can We Talk? Priorities for Patient Care Differed Among Health Care Providers (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Evanoff.pdf
      January 01, 2003 - Efforts to improve health care safety and quality are dependent on teamwork and are jeopardized by the … Advances in Patient Safety: Vol. 1 8 Results Reported communication between health care providers … There was Advances in Patient Safety: Vol. 1 10 Table 3. … Advances in Patient Safety: Vol. 1 14 19. Fuss MA, Bryan YE, Hitchings KS, et al. … Anaesthetists’ attitudes to teamwork and safety. Anaesthesia 2003;58(3):233–42. 22.

9591. Prologue—Volume 1—Five Years Later—Are We Any Safer? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/James.pdf
      January 01, 2004 - on the execution of patient safety efforts, and catalogued four major barriers at that level: 1. … Advances in Patient Safety: Vol. 1 2 4. … Patient safety represents a difficult and complex problem. Dr. … We all hold the future of patient safety in our hands. … Patient safety proves elusive. Mod Healthc 2004 Nov 1;pp. 6–7, 24–5, 30, 32. 4. Blendon RJ.

9592. Organizational Climate, Stress, and Error in Primary Care: The MEMO Study (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Linzer.pdf
      January 01, 2002 - Advances in Patient Safety: Vol. 1 66 Introduction While much research has focused on stress among … Advances in Patient Safety: Vol. 1 68 The clinician survey was derived in part from our Physician … Advances in Patient Safety: Vol. 1 72 Table 3. … Proceedings of the Second Annenberg Conference on Safety; Rancho Mirage, CA. … National Patient Safety Foundation at the AMA; 1998. p.151–54. 20.

9593. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
      January 01, 2003 - nurse education, and hospital procedures have been identified as important risk factors for patient safety … The study of proximate causes of errors and other sudden-onset events may be Advances in Patient Safety … Advances in Patient Safety: Vol. 1 56 Table 1. … Additionally, we restricted our enrollment criteria to Advances in Patient Safety: Vol. 1 62 … Advances in Patient Safety: Vol. 1 64 23. Potter P, Barr N, McSweeney M, et al.

9594. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
      March 15, 2004 - Advances in Patient Safety: Vol. 1 276 The few studies that have used comparison groups have focused … Initial Cases Advances in Patient Safety: Vol. 1 278 surgical occurrences for an elderly population … Advances in Patient Safety: Vol. 1 284 Table 3. … It may be valuable to target peripheral vascular bypass and colorectal resection in patient safety … Advances in Patient Safety: Vol. 1 288 Funding for this project came from the Centers for Medicare

9595. 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.

9596. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
      April 18, 2004 - Advances in Patient Safety: Vol. 1 84 Table 1. … VISN 8 Patient Safety Center, Tampa, FL (AMS, RRC, CC, PP). … Suncoast Center for Patient Safety, Tampa, FL (AMS, RRC, JW). … Florida Patient Safety Center, Inc. (AMS, RRC). … Advances in Patient Safety: Vol. 1 98 48.

9597. Developing a Taxonomy for Coding Ambulatory Medical Errors: 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/vol2/Pace.pdf
      January 01, 2004 - Methods: Individuals in 34 primary care practices reported medical errors to a Patient Safety Reporting … From a second view, promoting primary care safety is all about improving communication. … Australian Patient Safety Foundation (APSF). … Organizing patient safety research to identify risks and hazards. … Advances in patient safety: From research to implementation. Vol 2, Concepts and methodology.

9598. The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Kohl.pdf
      April 01, 2004 - Introduction Why is immunization safety research important? … How are immunization safety data collected? … How do case definitions assist the safety assessment of medical interventions? … Advances in Patient Safety: Vol. 2 92 F ig u re 1 . … Advances in Patient Safety: Vol. 2 102 46.

9599. Taxonomic Guidance for Remedial Actions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
      December 23, 2004 - Conclusion: This system could assist when addressing safety problems. … The facility had a problem with preventive maintenance of its Advances in Patient Safety: Vol. 2 … As in the Eindhoven taxonomy, slips Advances in Patient Safety: Vol. 2 80 Figure 1. … A Advances in Patient Safety: Vol. 2 82 Figure 3. … Medication Safety Alert, June 2, 1999.

9600. Medical Injury Identification Using Hospital Discharge Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Layde.pdf
      January 01, 2003 - on in-hospital patient safety problems. … It provides a more accurate estimate of the full scope of patient safety problems. … Patient safety efforts should focus on medical injuries. JAMA 2002;287(15):1,993–7. 3. … Patient safety indicators: using administrative data to identify potential patient safety concerns. … Advances in Patient Safety: Vol. 2 132 23.