Scanning the Headlines: Patient Safety

Updated on August 2, 2006

Links to full-text articles are provided where available.
For information on obtaining print copies of articles, please call the
AHA Resource Center at (312) 422-2050.


Aspden, P., and others, editors.  Preventing Medication Errors: Quality Chasm Series.  Washington:  The National Academies Press, 2007. 

Serb, C.  Medication and delivery.  Hospitals and Health Networks.  5(1):22-28, Winter 2006.

Grant, M., and others.  The safety culture in a children's hospital.  Journal of Nursing Care Quality.  221(3):223-229, July/Sept. 2006.

Nowinski, C.,  and Mullner, R.  Patient safety:  solutions in managed  care organizations?  Quality Management in Health Care.  15(3):130-136, July/Sept. 2006.

Schaffer, R.  First step to patient safety bar codes or CPOE?  Hospital and Health Networks.  Web Exclusive.  Aug. 2, 2006.

Rogoski, R.  Building a safety net.  Health Management Technology.  27(8):12-16, Aug. 2006.

Helpful solutions for meeting the 2007 national patient safety goals.  Joint Commission Perspectives on Patient Safety.  6(8):1-2, Aug. 2006.

Reducing the risk of suicide.  Joint Commission Perspectives on Patient Safety.  6(8):5-6, Aug. 2006.

Reducing the risk of home fires.  Joint Commission Perspectives on Patient Safety.  6(8):6, Aug. 2006.

Involving patients in their care.  Joint Commission Perspectives on Patient Safety.  6(8):7-8, Aug. 2006.

Improving handoff communications.  Joint Commission Perspectives on Patient Safety.   6(8):9-10, 15, Aug. 2006.

Haglund, M.  Safety when it counts:  patient safety moves forward in some hospitals but, seven years after the "quality chasm" report, progress is still spotty.  Healthcare Informatics.  23(8):30-34, Aug 2006.

Midget, J.  Infection protection:  surveillance technologies can help healthcare organizations better detect and respond to infections.  Healthcare Informatics.  23(8):46-50, Aug 2006.

Performing medication reconciliation in short-stay areas.  Joint Commission Perspectives on Patient Safety.   6(8):11-12, 15, Aug. 2006.

Reporting critical test results.  Joint Commission Perspectives on Patient Safety.   6(8):13-14, Aug. 2006.

Borckardt, J., and others.  How unusal are the "unusal events" detected by control chart techniques in healthcare settings?  Journal for Healthcare Quality.  28(4):4-9, July/Aug. 2006.

Guinane, C.  Mikel Harry on Six Sigma in healthcare.  Journal for Healthcare Quality.  28(4):29-36, July/Aug. 2006.

Dagnone, R., and others.   How do patients perceive electronic documentation at the bedside?  Journal for Healthcare Quality.  28(4):37-44, July/Aug. 2006.

Fracia, P., Minnich, M., and Fabius, R.  Patient safety checklist:  keys to successful implementation.  Physician Executive.  32(4):46-48, July/Aug. 2006.

Meyers, J.  HCA's perinatal safety initiative removes variation and improves outcomes.  Healthcare Executive.  21(4):26-29, July/Aug. 2006.

Mages, M.  Quality-driven healthcare.  Healthcare Executive.   21(4):60-62, July/Aug. 2006.

Rapid response terms:  ten essentials leaders need to know.  Healthcare Executive.  21(4):30-34, July/Aug. 2006.

Meyers, S.  Standardizing safety.  Trustee.  59(7):12-14, 21, July/Aug. 2006.

Bradley, E., and others.  Hospital quality for acute myocardial infraction.  Journal of the American Medical Association.  (JAMA).  296(1):72-78, July 5, 2006.

New patient safety goal:  involve your patients.  ED Management.  18(7):82, July 2006.

Pharm, S., and others.  Improving the safety of intrabenous admixtures:  lessons learned from a Pentostam® overdose.  Joint Commission Journal of Quality and Patient Safety.  32(7):366-372, July 2006.

Woods, J., and Shultz, J.  Using HFMEA  to assess potential for patient harm form tubing misconnections.  Joint Commission Journal of Quality and Patient Safety.  32(7):373-381, July 2006.

King, E., and others.  Getting doctors to report medical errors:  project DISCLOSE.  Joint Commission Journal of Quality and Patient Safety.  32(7):382-391, July 2006

Heuvel, J., and others.  Implementing Six Sigma in the Netherlands.  Joint Commission Journal of Quality and Patient Safety.   32(7):393-399, July 2006

Lezzoni, L.  Improving health care quality and safety for people with disabilities:  An interview with Lisa Lezzoni.  Joint Commission Journal of Quality and Patient Safety.  32(7):400-410, July 2006

Tubing misconnections a persistent and potentiallly deadly occurence.  Sentinel Event ALERT.  Issue 36, Apr. 3, 2006.  Joint Commission Journal of Quality and Patient Safety.  32(7):411-414, July 2006

The Joint Commission announces the 2007 national patient safety goals and requirements.  Joint Commission Perspectives.  26(7):1, 5, July 2006.

Seven-step risk assessments.  Joint Commission Perspectives on Patient Safety.  6(7):5-7, July 2006.

How hospitalists contribute to patient safety.  Joint Commission Perspectives on Patient Safety.  6(7):11, July 2006.

Briggs, E.  Partnering to save lives.  Rural Roads.  4(2):12-13, July 2006.

What do JCAHO surveyors look for in assessing the universal protocol?  OR Manager.  22(7):1, 7-9, July 2006.

Ensuring consistent time-out in a system.  OR Manager.  22(7):10-11, July 2006.

Using computer's data to guide OR QI.  OR Manager.   22(7):18, 21, July 2006.

Kaiser, N., and Sandhu, S.  The role of skin science in assuring hand hygiene compliance. Healthcare Purchasing News.   30(7):36-38, July 2006.

Kenefick, C., and others.  Breaking the silence for patient safety.  MLA News.  June/July 2006.

Weber, T., and Ornstein, C.  20% of U.S. transplant centers are found to be substandard.  Los Angeles Times.  June 29, 2006.

Landro, L.  Hospitals combat errors at the 'hand -off'.  The Wall Street Journal.   Page D.  June 28, 2006.

Hospital initiative to cut errors finds about 122,300 lives saved.  Wall Street Journal.  June 15, 2006.

ED located next to ICU to bolster patient safety.  ED Management.   18(6):67-69, June 2006.

McBride, D.  Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.  Healthcare Financial Management.  60(6):84-88, June 2006.

Bry, K., Stettner, B., and Marks, J.  Patient safety:  through the eyes of your peers.  Nursing Management.  37(6):20-24, June 2006.

McBride, D., Greening, A., and Redmond, D.  Path to safety:  benefits of the 2005 patient safety and quality improvement act.  Healthcare Financial Management Association.  60(6):84-88, June 2006.

Blair, R.  Passing the "yo' mama" test.  Health Management Technology.  27(6):14-18, June 2006.

Designing a healing environment.  Health Facilities Management.  19(6):30-40, June 2006.

Are site-vertification protocols too complex?  OR Manager.  22(6):7, June 2006.

A safer alternative to safety scalpels?  OR Manager.  22(6):25, June 2006.

AORN updates sterilization guidelines.  OR Manager.  22(6):21-22, June 2006.

Is that patient's postoperative skin injury really a burn?  OR Manager.  22(6):22-23, June 2006.

Heneghan, K., Sachdeva, A., and McAninch, J.  Transformation to a system that supports full patient participation.  Bulletin.  91(6):11-19, June 2006.

Healy, G., Barker, J., and Madonna, G.  Error reduction through team leadership:  seven principles of CRM applied to surgery.  Bulletin.  91(6):24-26, June 2006.

Pryor, D., and others.  The clinical transformation of ascension health:  eliminating all preventable injuries and deaths.  Joint Commission Journal on Quality and Patient Safety.  32(6):299-308, June 2006.

Kowiatek, J., and others.  Assessing and monitoring override medications in automated dispensing devices. Joint Commission Journal on Quality and Patient Safety.  32(6):309-317, June 2006.

Stop going through the motions.  Joint Commision Perspectives on Patient Safety.  6(6):1-2, 8, June 2006.

Prescribing with caution.   Joint Commision Perspectives on Patient Safety.  6(6):7, June 2006.

AHA quality center:  new one-stop resource helps leaders improve quality.  HR Pulse.():16-23, Summer 2006.

Six Aims:  Institute of Medicine's report on quality still resonates.  HR Pulse.  ():24, Summer 2006.

Answer/evaluation form:  overcoming barriers to patient safety.  Nursing Economics.  24(3):149, May/June 2006.

Siegel, E., and Bennett, P.  Creating partnerships through patient safety awareness week.  Nursing Economics.  24(3):162-165, May/June 2006.

Hendrich, A.  Inpatient falls:  lessons from the field.  Patient Safety & Quality Healthcare.  3(3):26-30, May/June 2006.

Woods, M.  The dun factor:  how communication complicates the patient safety movement.  Patient Safety & Quality Healthcare.  3(3):40-44, May/June 2006.

Grinten, P.  Rhios aim to transform quality of care and patient safety.  Patient Safety & Quality Healthcare.  3(3):46-48, May/June 2006

Feder, H.  Implementation of patient safety organizations expected by end of year.  Health Care Compliance.  8(3):49-52, May/June 2006.

Poole, D.  Medication reconciliation:  a necessity in promoting a safe hospital discharge.  Journal for Healthcare Quality.  28(3):12-19, May/June 2006.

Smith, T.  Honorees seek to improve patient safety.  Richmond Times Dispatch.  May 25, 2006.

Study: video games can help out surgical errors.  CNN.com, May 24, 2006.

Studdert,, D.and others.  Claims, errors, and compensation payments in medical malpractice litigation.  New England Journal of Medicine.  354(19):2024-2033, May 11, 2006.

Annas, G.  The patient's right to safety--improving the quality of care through litigation against hospitals.  New England Journal of Medicine.  354(19):2063-2066, May 11, 2006.

Felt-Lisk, S.  New hospital information technology: is it helping to improve quality?  Issue Brief.  No. 3.  May 2006.

Code pink:  the frightening phenomenon of infant abductions in hospitals.  The Hospitalist.  10(5):43-47, May 2006.

Elder, N.  Patient safety in the physicians office setting.  AHRQ WebM&M.  May 2006.

Kanushal, R., and others.  The wild west: patient safety in office-based anesthesia.  AHRQ WebM&M.  May 2006.

Laschinger, H., and Leiter, M.  The impact of nursing work environments on patient safety outcomers.  Journal of Nursing Administration (JONA).  36(5):259-267, May 2006.

This ED uses simulators to reduce pediatric errors.  ED Management.  18(5):51-52, May 2006.

Anderson, J.  Avoid getting 'lost in translation' with six simple tips.  Healthcare Marketing Advisor.  7(5):4, May 2006.

Sheridan, D.  Labeling solutions and medications in sterile procedural settings.  Joint Commission Journal of Quality and Patient Safety.  32(5):276-282, May 2006.

Empower staff and improve patient safety.  Joint Commission Perspectives on Patient Safety.  6(5):9-10, May 2006.

Medication errors highest in radiology.  Joint Commission Perspectives on Patient Safety.   6(5):11, May 2006.

Keeping patients safe during a disaster.  Joint Commission Perspectives on Patient Safety.  6(5):1-3, May 2006.

Hampton, T.  Hospital bed entrapments.  Journal of the American Medical Association.  295(16):1889, Apr. 26, 2006.

Robeznieks. A.  High priority, low progress.  Modern Healthcare.  36(15):31-32, Apr. 10, 2006.

Kwaan, M.  Incidence, patterns, and prevention of wrong-site surgery.  Archives of Surgery.   141(4):353-358, Apr. 2006.

McCarthey, D., and Blumenthal, D.  Committed to safety: ten case studies on reducing harm to patients.  The Commonwealth Fund.  Apr. 2006.

Is your organization linguistically competent?  Joint Commission Perspectives on Patient Safety.  6(4):1, 2, 8, Apr. 2006.

The sound of patient safety.  Patient Safety.  6(4):3-4, Apr. 2006.

Lean thinking promotes patient safety.  Patient Safety.   6(4):11, Apr. 2006.

Overcoming barriers to quality.  Hospitals and Health Networks.  80(4):insert 1-9, Apr. 2006.

Josh, M., and Hines, S.  Getting the board on board:  engaging hospital boards in quality and patient safety.  Journal on Quality and Patient Safety.  32(4):179-187, Apr. 2006.

Kaldjian, L., Jones, E., and Rosenthal, G.  Facilitating and impeding factors for physicians' error disclosure:  a structured literature review.  Journal on Quality and Patient Safety.  32(4):188-198, Apr. 2006.

Turley, J., and others.  Operating manual-based usability evaluation of medical devices:  an effective patient safety screening method.  Journal on Quality and Patient Safety.   32(4):214-220, Apr. 2006.

Santell, J.  Reconciliation failures lead to medication errors.  Journal on Quality and Patient Safety.   32(4):225-229, Apr. 2006.

Using medication reconciliation to prevent errors.  Journal on Quality and Patient Safety.   32(4):230-232, Apr. 2006.

Kruger, N., Hutley, A., and Gustafson, M.  Framing patient safety initiatives.  Journal of Nursing Administration.  36(4):200-204, Apr. 2006.

Kwaan, M., and others.  Incidence, patterns, and prevention of wrong-site surgery.  Archives of Surgery.  141(4):353-357, Apr. 2006.

Creative approaches to handoffs help meet JCAHO's safety goal.  OR Manager.  22(4):1, Apr. 2006.

'Passing the baton' for smooth handoffs.  OR Manager.  22(4):13-14, Apr. 2006.

A shared tool strengthens handoffs.  OR Manager.  22(4):15, Apr. 2006.

ASC safety begins with patient selection.  OR Manager.   22(4):25-27, Apr. 2006.

Tips for introducting SBAR in the OR.  OR Manager.  22(4):12, Apr. 2006.

What does JCAHO expect for handoffs?  OR Manager.   22(4):11, Apr. 2006.

Crucial conversations:  a key for safety.  OR Manager.  22(4):7, 9, Apr. 2006.

Goth, G.  Raising the bar.  Healthcare Informatics.  23(4):38-41, Apr. 2006.

Health Grades Quality Study: Third Annual Patient Safety in American Hospitals Study.  Health Grades, Inc.  Apr. 2006. 

Nestor, C.  Reducing medical drug errors.  Facilty Care.  11(2):18-19, Mar./Apr. 2006.

Piechowski, R.  Making CPOE work:  redesign workflows to optimize benefits.  Patient Safety & Quality Healthcare.   3(2):28-30, Mar./Apr. 2006.

McFadden, K., Stock, G., and Gowen, C.  Exploring strategies for reducing hospital errors.  Journal of Healthcare Management.  51(2):123-135, Mar./Apr. 2006.

Schoenbaum, S., and Segel, K.  Long-term solution to malpractice crises:  reduce harm to patients.  Physician Executive.  32(2):26-31, Mar./Apr. 2006.

Harmon, K.  Naval aviation safety and its application to medicine.  Patient Safety & Quality Healthcare.  3(2):20-26, Mar./Apr. 2006.

Piechowski, R.  Making CPOE work:  redesign workflows to optimize benefits.  Patient Safety & Quality Healthcare.  3(2):28-30, Mar./Apr. 2006.

The sound of patient safety.  Joint Commission Perspectives on Patient Safety.  6(4):3-4, Apr. 2006.

Lean thinking promotes patient safety.  Joint Commission Perspectives on Patient Safety.  6(4):11, Apr. 2006.

Leonard, M., and Frankel, A.  Make safety a priority create and maintain a culture of patient safety.  Healthcare Executive.  21(2):12-18, Mar./Apr. 2006.

Sherman, J.  Patient safety:  engaging medical staff.  Healthcare Executive.  21(2):20-23, Mar./Apr. 2006.

Bader, B.  Quality and patient safety:  Engaging your board to take the lead.  Healthcare Executive.  21(2):64-67, Mar./Apr. 2006.

Winterstein, A., and others.  Medication safety infrastructure in critical-access hospitals in Florida.  American Journal of Health-System Pharmacy.  63(5):442-450, Mar. 1, 2006.

Study of perioperative med errors provides clues for improving care.  OR Manager.  22(3):1, 8-9, Mar. 2006.

Cell phone use in OR could improve patient safety, a survey shows.  OR Manager.  22(3):7, Mar. 2006.

How patients are harmed by periop medication errors.  OR Manager.  22(3):9, Mar. 2006.

Strategies for preventing med errors.  OR Manager.  22(3):11, 13, Mar. 2006.

Barlow, R.  Up close:  hospitals must come clean about a dirty secret.  Healthcare Purchasing News.  30(3):16,19, Mar. 2006.

RID's 14 steps to reduce hospital infection risk.  Healthcare Purchasing News.  30(3):20, Mar. 2006.

RID's model hospital infection report card bill.  Healthcare Purchasing News.  30(3):22, Mar. 2006.

Ervin, N.  Does patient satisfaction contribute to nursing care quality?  Journal of Nursing Administration.  36(3):126-130, Mar. 2006.

Jones, S., and Moss, J.  Computerized provider order entry.  Journal of Nursing Administration.  36(3):136-139, Mar. 2006.

Newhouse, R.  Selecting measures for safety and quality improvement initiatives.  Journal of Nursing Administration.  36(3):109-113, Mar. 2006.

Barry, J.  The hovermatt system for patient transfer.  Journal of Nursing Administration.  36(3):114-117, Mar. 2006.

Pronovost, P., and others.  A web-based tool for the comprehensive unit-based safety program (CUSP).  Joint Commission Journal on Quality and Patient Safety.  32(3):119-129, Mar. 2006.

Robinson, D., Heigham, M., and Clark, J.  Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer.  Joint Commission Journal on Quality and Patient Safety.  32(3):161-166, Mar. 2006.

Haig, K., Sutton, S., and Whittington, J.  SBAR:  a shared mental model for improving communication between clinicians.  Joint Commission Journal on Quality and Patient Safety.  32(3):167-175, Mar. 2006.

Patients first:  commitment to continuous improvement in patient safety.  Joint Commission on Patient Safety.  6(3):7-8, Mar. 2006.

Preventing retained foreign objects.  Joint Commission on Patient Safety.  6(3):11, Mar. 2006.

Sentinel event:  using medication reconciliation to prevent errors.  Joint Commission Perspectives.  26(3):13-14, Mar. 2006.

Update:  sentinel events statistics.  Joint Commission Perspectives.  26(3):8, Mar. 2006.

Training from fighter pilots helps some hospitals decrease medical errors.  Healthcare Financial Management.  60(3):28, Mar. 2006.

Falik, M., and others.  Comparative effectiveness of health centers as regular source of care.  Journal of Ambulatory Care Management.  29(1):24-35, Jan./Mar. 2006.

Martin, R.  Federal, state, and public--private responses to medical error and patient safety:  an overview.  Health Lawyers Weekly.  Feb. 17, 2006.

Zhan, C., and others.  Potential benefits and problems with computerized prescriber order entry:  analysis of a voluntary medication error-reporting database.  American Journal of Health System Pharmacy.  63(4):353-358, Feb. 15, 2006.

Getting a grip on costs and usage of spinal implant technologies. OR Manager.  22(2):1, 8, 11, Feb. 2006.

Surgery strong on safety, but hospitals have long way to go.  OR Manager.  22(2):7, Feb. 2006.

Royal, S., and others.  Interventions in primary care to reduce medication related adverse events and hospital admissions:  systematic review and meta-analysis.  Quality & Safety in Health Care.  15(1):23-31, Feb. 2006.

Pick a CPOE that's right for your ED and hospital.  ED Management.  18(2):16-17, Feb. 2006.

Rothschild, J., and others.  Recovery from medical errors:  the critical care nursing safety net.  Joint Commission Journal on Quality and Patient Safety.  32(2):63-72, Feb. 2006.

Cina, J., and others.  How many hospital pharmacy medication dispensing errors go undetected?  Joint Commission Journal on Quality and Patient Safety.  32(2):73-80, Feb. 2006.

Gaynes, R., and Platt, R. Monitoring patient safety in health care:  building the case for surrogate measures.  Joint Commission Journal on Quality and Patient Safety.  32(2):95-101, Feb. 2006.

Pronovost, P., and others.  A practical tool to learn from defects in patient care.  Joint Commission Journal on Quality and Patient Safety.  32(2):102-108, Feb. 2006.

Healy, G., Barker, J., and Madonna, G.  Error reduction through team leadership:  applying aviation's CRM model in the OR.  Bulletin.  91(2):10-15, Feb. 2006.

Maviglia, S.  Delivering informed care.  Health Management Technology.  27(2):26-28, Feb. 2006.

Dickinson, R.  Blueprint for safety.  HealthLeaders.  9(2):14, Feb. 2006.

Baldwin, G.  Running stop signs.  HealthLeaders.  9(2):33-34, Feb. 2006.

Greene, J.  Information technology may not be 'it' for patient safety.  Trustee.  59(2):7-10, Feb. 2006.

Improving safety in rural hospitals.  Joint Commission Perspectives Patient Safety.  6(2):1-2, 4, Feb. 2006.

Part II:  evaluating the risk points in your medication management system.  Joint Commission Perspectives Patient Safety.  6(2):5, 8, Feb. 2006.

Labeling in the laboratory.  Joint Commission Perspectives Patient Safety.  6(2):11, Feb. 2006

Haswell, P.  Improving safety in obstetrics with decision support and clinical it.  Patient Safety & Quality Healthcare.  3(1):40-42, Jan./Feb. 2006.

Ettel, D., and Wilson, C.  Medication errors:  focus on legibility.  Patient Safety & Quality Healthcare.  3(1):52-,54 Jan./Feb. 2006.

Kahlon, P.  Patient safety:  a collaborative, blame-free, team approach.  Radiology Management.  28(1):47-50, Jan./Feb. 2006.

Kee, L., and Cheramy, K.  Patient safety efforts at SSM health care.  Health Progress.  87(1):21, Jan./Feb. 2006.

Ballard, L.  Putting safety at the core.  Health Progress.  87(1):29-34, Jan./Feb. 2006.

Conlon, P., and Gartner, G.  A jury of our peers.  Health Progress.  87(1):39-42, Jan./Feb. 2006.

Using medication reconciliation to prevent errors.  Sentinnel Event Alert.  (35):Jan. 23, 2006.

Harris, G.  New regulations for drug labels aim to cut medical errors.  New York Times.  Jan. 18, 2006.

Cina, J., and others.  Medication errors in a pharmacy-based bar-code-repackaging center.  American Journal of Health-System Pharmacy (AJHP).  63(2):165-168, Jan. 15, 2006.

Schneider, P., and others.  Improving the safety of medication administration using an interactive CD-Rom program.  American Journal of Health-System Pharmacy.  63(1):59-64, Jan. 1, 2006.

Are handoffs too 'automatic'? QI experts fear errors could rise.  Healthcare Benchmarks and Quality Improvement.  13(1):1-4, Jan. 2006.

Williamson, J.  Operating Room:  Surgical errors:  new products, protocols help slash the risks.  Healthcare Purchasing News.  30(1):22-24, Jan. 2006.

Hoff, T., and Sutcliffe, K.  Studying patient safety in health care organizations:  accentuate the qualitative.  Joint Commission Journal on Quality on Patient Safety.  32(1):5-15, Jan. 2006.

Rogers, G., and others.  Reconciling medications at admission:  safe practice recommendations and implementation strategies.  Joint Commission Journal on Quality on Patient Safety.  32(1):37-49, Jan. 2006.

Kaldy, J.  E-prescribing is e-slow.  The Hospitalist.  10(1):16-18, Jan. 2006.

Part I:  identifying risks in the medication use process.  Joint Commission Perspectives on Patient Safety.  6(1):3-4, 6, Jan. 2006.

Including patients in hospital management decisions.  Joint Commission Perspectives on Patient Safety.  6(1):9,11, Jan. 2006

Switching to single-dose containers.  Joint Commission Perspectives on Patient Safety.  6(1):10, Jan. 2006

Medical errors:  if you're not part of the solution, your're part of the problem.  MGMA Connexion.  6(1):20-21, Jan. 2006.

New VHA program aims to transform ORs into money-saving, life-saving operations.  Health Care Strategic Management.  24(1):6, Jan. 2006.

CPOE:  It's not a matter of if, but when, say the experts, so the time to prepare is now.  ED Management.  18(1):1-3, Jan. 2006.

Rozovsky, F., Gilk, T., and Latino, R.  Taking risky business out of the MRI suite.  Materials Management in Healthcare.  15(1):18-23, Jan. 2006.

Rollins, G.  Medication safety.  HealthLeaders.  9(1):41, Jan. 2006.

Force, M., and others.  Effective strategies to increase reporting of medication errors in hospitals.  Journal of Nursing Administration (JONA).  36(1):34-41, Jan. 2006.

Patient -safety programs improve, but more needs to be done, researchers say.  Hospitals & Health Networks.  80(1):61-72, Jan. 2006.

Gosfield, A., and Reinertsen, J.  Longwoods Review:  the 100,000 lives campaign:  crystallizing standards of care for hospitals.  Healthcare Quarterly.  4(2):1-5, 2006.

Reinertsen, J., and Baker, G.  A conversation about leadership and quality with James Reinertsen and G. Ross Baker.  Healthcare Quarterly.  4(2):10-12, 2006.

Manno, M., and others.  Patient-safety survey report.  Nursing2006.  36(5):1-11, 2006

Stelfox, H., and others.   The "to err is human" report and the patient safety.  Quality Safety in Health Care.  15(10):174-178, 2006.

Royal, S., and others.  Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis.  Quality Safety in Health Care.  15(10):23-31, 2006.

Kilbridge, P., Welebob, E., and Classen, D.   Development of the leapforg methodology for evaluating hospital implemented inpatient computerized physician order entry systems.  Quality Safety in Health Care.  15(10):81-84, 2006.

Gosbee, J., editor.  Using human factors engineering to improve patient safety.  Oakbtook Terrace, IL:  Joint Commission Resources, 2005.  (WX 185 U85 2005).

Jeffs, L.  and others.  Case study:  reconciling the quality and safety gap through strategic planning.  Nursing Leadership.  19(2):32-40, 2006.

West, J.  Surgical 'never events':  how common are adverse occurrences?  Journal of Healthcare Risk Management.  26(1):15-21, 2006.

Murphy, T.  CCHSA client/patient safety culture assessment project:  lessons learned.  Healthcare Quarterly.   9(2):52-54, 2006.

A dialogue on quality and patient safety with Maureen Bisognano.  Nursing Leadership.  19(1):21-25, 2006.

Ferguson-Pare, M.  A sabbatical journey of discovery:  patient safety.  Nursing Leadership.  19(1):18-20, 2006.

Leatt, P., and others.  IT solutions for patient safety-best practices for successful implementation in healthcare.  Healthcare Quarterly.  9(1):94-104, 2006.

Wu, R., and others.  Implementation of a computerized physician order entry system of medications at the university health network-physicians' perspectives on the critical issues.  Healthcare Quarterly.  9(1):106-109, 2006.

Bisognano, M., and Plsek, P.  10 More Powerful Ideas for Improving Patient Care.  Chicago:  Health Administration Press, 2006.  (W 84.1 B622z 2006).

Pedersen, C., Schneider, P., and Scheckelhoff, D.  ASHP National Survey of Pharmacy Practice in Hospital Settings: Dispensing and Administration--2005. American Journal of Health-System Pharmacy.  63(4):327-45, 2006.

Cummings, J., and others.  Bar-coding medication administration overview and consensus recommendations.  American Journal of Health-System Pharmacy (AJHP).  62(24):2626-2629, Dec. 15, 2005.

Longo, D., Hewett, J., and Schubert, S.  The long road to patient safety:  a status report on patient safety systems.  JAMA.  294(22):2858-2865, Dec. 14, 2005.

Creamer, J., and Elliot, P.  Embedded coaches lead to CPOE victory.  Health Management Technology.  26(12):26-28, Dec. 2005.

McBride, M., editor.  Raising the bar.  Health Management Technology.  26(12):32-33, Dec. 2005.

O'Flaherty, N., and others.  How FDA hopes to decrease medical errors with the help of bar code technology.  Health Lawyers News.  9(12):4-10, Dec. 2005.

Seeking a just culture to design a safet hospital environment.  Quality Letter for Healthcare Leaders.  17(12):8-10, Dec. 2005.

Crosby, C.  Hand hygiene:  are we doing better?  Healthcare Purchasing News.  29(12):36-37, Dec. 2005.

Involving patients in stroke care.  Joint Commission Perspectives on Patient Safety.  5(12):1-2, 4, Dec. 2005.

Turning on anesthesia alarms.  Joint Commission Perspectives on Patient Safety.  5(12):3, Dec. 2005.

Defensive medicine.  Joint Commission Perspectives on Patient Safety.  5(12):5, Dec. 2005.

No excuses for not improving patient safety.  Joint Commission Perspectives on Patient Safety.  5(12):6-7, Dec. 2005.

Woods, D., and others.  Anatomy of a patient safety event:  a pediatric patient safety.  Quality & Safety in Health Care.  14(6):422-427, Dec. 2005.

Weiner, S.  Radiology by nonradiologists:  is report documentation adequate?  American Journal of Managed Care.  11(12):781-785, Dec. 2005.

Patient safety taxonomy approved.  Joint Commission Perspectives on Patient Safety.  5(12):8, Dec. 2005.

Sharing information at transfers.  Joint Commission Perspectives on Patient Safety.  5(12):9-10, Dec. 2005.

Surgical care improvement project.  Joint Commission Perspectives on Patient Safety.  5(12):11, Dec. 2005.

Medication errors.  HealthLeaders.  8(12):Insert, Dec. 2005.

Maulik, J., and others.  A comprehensive grassroots model for statewide safety improvement.  Joint Commission Journal on Quality and Patient Safety.  31(12):671-677, Dec. 2005.

Quinn, M., and Mannion, J.  Improving patient safety using interactive, evidence-based decision support tools.  Joint Commission Journal on Quality and Patient Safety.  31(12):678-683, Dec. 2005.

Schmidek, J., and Weeks. W.  What do we know about financial returns on investments in patient safety?  Joint Commission Journal on Quality and Patient Safety.  31(12):690-699, Dec. 2005.

Yates, G., and others.  Building and sustaining a systemwide culture of safety.  Joint Commission Journal on Quality and Patient Safety.  31(12):684-689, Dec. 2005.

Thompson, P., Navarra, M., and Antonson, N.  Patient safety:  the four domains of nursing leadership.  Nursing Economics.  23(6):331-333, Nov./Dec. 2005.

Cutler, D., Feldman, N., and Horwitz, J.  U.S. adoption of computerized physician order entry systems.  Health Affairs.  24(6):1654-1663, Nov./Dec. 2005.

Haig, K.  Culture improves safety:  reducing adverse drug events.  Patient Safety & Quality Healthcare.  2(6):22-25, Nov./Dec. 2005.

Dotan, D.  Patient safety officers:  roles and responsibilities.  Patient Safety & Quality Healthcare.  2(6):32-34, Nov./Dec. 2005.

Sabharwal, A.  New roles improve bed utilization.  Patient Safety & Quality Healthcare.  2(6):36-38, Nov./Dec. 2005.

Wolosin, R., Vercler, L., and Matthews, J.  How safe do patients feel?  Patient Safety & Quality Healthcare.   2(6):40-44, Nov./Dec. 2005.

Woods, M.  What if we just said, "I'm sorry"?  Patient Safety & Quality Healthcare.  2(6):46-48, Nov./Dec. 2005.

Burke, M.  Informed consent enters a new age.  Patient Safety & Quality Healthcare.  2(6):52-53, Nov./Dec. 2005.

Roleti, R.  Leading the way to safer, more effective care.  Patient Safety & Quality Healthcare.  2(6):54-55, Nov./Dec. 2005

Carroll, V.  Is patient safety synonymous with quality nursing care?  should it be?  a brief discourse.  Quality Management in Health Care.  14(4):229-233, Oct./Dec. 2005.

Pratt, N., Thomas, L., and Atkins, P.  Measure patient harm in real time.  Nursing Management.  36(11):17-19, Nov. 2005.

Joch, A.  Keeping tabs on product recall alerts.  Materials Management in Health Care.  14(11);30-32, Nov. 2005.

Toft, B., and Taylor, H.  Involuntary automaticity:  a work-system induced risk to safe health care.  Health Services Management Research.  18(4):211-216, Nov. 2005.

Sharps safety.  Materials Management in Health Care.  14(11);34, Nov. 2005.

Baldwin, G.  Bringing order to CPOE.  HealthLeaders.  8(11):24-36, Nov. 2005.

Prisoners, guns can be deadly combination in the emergency room.  Ed Management.  17(11):121-123, Nov. 2005.

Gandhi, T.  Closing the loop:  follow-up and feedback in a patient safety program.  Joint Commisssion Journal on Quality and Patient Safety.  31(11):614-621, Nov. 2005.

Santell, J., and Cousins, D.  Medication errors related to product names.  Joint Commisssion Journal on Quality and Patient Safety.  31(11):649-653, Nov. 2005.

Patient-inclusive care.  Joint Commission Perspectives on Patient Safety.  5(11):1-2, 8, Nov. 2005.

Putting an end to do-not-use abbreviations.  Joint Commission Perspectives on Patient Safety.  5(11):3-4, Nov. 2005.

Actionable error reporting systems.  Joint Commission Perspectives on Patient Safety.  5(11):5-6, Nov. 2005.

Improving medication adherence.  Joint Commission Perspectives on Patient Safety.  5(11):9-10, Nov. 2005.

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