Scanning the Headlines: Patient Safety (Archive) 2008

  
Updated on July 26, 2010

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Leadership, culture and medication safety.  H & HN Online.   Web Exclusive.   Winter 2008.

Trapp, D.  HHS sets rules for confidential medical error reporting systemAmednews.com.  Dec. 15, 2008.

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.  Washington:  Institute of Medicine of the National Academies, Dec. 2, 2008.

Gilbert, L., and others.  Aligning hospital and physician performance incentives a shared success model.  Joint Commission Journal on Quality and Patient Safety.  34(12): 703-706, Dec.2008.

Cousins, D., and Heath, W.   The national coordinating council for medication error reporting and prevention: promoting patient safety and quality through innovation and leadership.  Joint Commission Journal on Quality and Patient Safety.  34(12): 700-702, Dec.2008.

Audet, A. and others.  Transparency as a pillar of a quality and safety culture: the experience of the New York City Health and Hospitals Corporation. Joint Commission Journal on Quality and Patient Safety. 34(12):707-712, Dec. 2008.

Koll, B., and others.  The clabs collaborative a regionwide effort to improve the quality of care in hospitals. Joint Commission Journal on Quality and Patient Safety. 34(12):713-722, Dec. 2008.

Myers, S., and others.  Focusing measures for performance based privileging of physicians on improvement.  Joint Commission Journal on Quality and Patient Safety. 34(12):724-733, Dec. 2008.

Hicks, R., and others.  Medication errors involving patient controlled analgesia.  Joint Commission Journal on Quality and Patient Safety. 34(12):734-742, Dec. 2008.

Benson, L., and others.  Using an advanced practice nursing model for a rapid response team.  Joint Commission Journal on Quality and Patient Safety. 34(12): 743-747, Dec. 2008.

Heder, B.  IOM urges more rest for residents in push to improve patient safety.  American Medical News.  51(48):1-2, Dec. 2008.

The physician’s role in medication reconciliation. Joint Commission Perspectives on Patient Safety. 8(12):1, 3-4, 7, Dec. 2008.

Learning from never events: one hospital’s reaction to a wrong-site surgery. Joint Commission Perspectives on Patient Safety. 8(12):8-10, Dec. 2008.

Taking steps to protect patients from specimen-handling errors.  OR Manager. 24(12):1,7-8, Dec. 2008.

Minnesota’s retained object protocol.  OR Manager. 24(12):14,16, Dec. 2008.

Robeznieks, A.  Sleeping in order. Modern Healthcare. 38(49):6-7, Dec. 2008.

DerGurahian, J.  Patient-safety efforts narrowed. Modern Healthcare. 38(49):10,Dec. 2008.

DerGurahian, J.  Providers, patient-safety advocates brainstorm on decreasing errors, bad attitudes.  Modern Healthcare. 38(49):26-28,Dec. 2008.

Largest patient-satisfaction measurement firms ranked by total number of engagements in 2007.  Modern Healthcare. 38(49):32,Dec. 2008.

Bar-code medication administration: a systems perspective.  American Journal of Health System Pharmacy. 65(23): 2216-2219, Dec. 2008.

In an area where decimal-point medication errors can be fatal, smart infusion pumps are adding a line of defense. Healthcare Informatics.  25(12):20, Dec. 2008.

Gamble, K. No sponge left behind. Healthcare Informatics.  25(12):34-39, Dec. 2008

Gilbert, L., and others.  Aligning hospital and physician performance incentives a shared success model.  Joint Commission Journal on Quality and Patient Safety.  34(12): 703-706, Dec. 2008.

Cousins, D., and Heath, W.   The national coordinating council for medication error reporting and prevention: promoting patient safety and quality through innovation and leadership.  Joint Commission Journal on Quality and Patient Safety.  34(12): 700-702, Dec. 2008.

Audet, A. and others.  Transparency as a pillar of a quality and safety culture: the experience of the New York City Health and Hospitals Corporation.  Joint Commission Journal on Quality and Patient Safety. 34(12): 707-712, Dec. 2008.

Koll, B., and others.  The clabs collaborative a regionwide effort to improve the quality of care in hospitals. Joint Commission Journal on Quality and Patient Safety. 34(12): 713-722, Dec. 2008.

Myers, S., and others.  Focusing measures for performance based privileging of physicians on improvement. Joint Commission Journal on Quality and Patient Safety. 34(12): 724-733, Dec. 2008.

Hicks, R., and others.  Medication errors involving patient controlled analgesia. Joint Commission Journal on Quality and Patient Safety. 34(12): 734-742, Dec. 2008.

Benson, L., and others.  Using an advanced practice nursing model for a rapid response team.  Joint Commission Journal on Quality and Patient Safety.  34(12): 743-747, Dec. 2008.

Heder, B.  IOM urges more rest for residents in push to improve patient safety.  American Medical News. 51(48):1-2, Dec. 2008.

The physician’s role in medication reconciliation. Joint Commission Perspectives on Patient Safety. 8(12):1, 3-4, 7, Dec. 2008.

Learning from never events: one hospital’s reaction to a wrong-site surgery. Joint Commission Perspectives on Patient Safety.  8(12):8-10, Dec. 2008.

Taking steps to protect patients from specimen-handling errors.  OR Manager. 24(12):1,7-8, Dec. 2008.

Minnesota’s retained object protocol.  OR Manager. 24(12):14,16, Dec. 2008.

Robeznieks, A.  Sleeping in order. Modern Healthcare. 38(49):6-7, Dec. 2008.

DerGurahian, J.  Patient-safety efforts narrowed. Modern Healthcare. 38(49):10,Dec. 2008.

DerGurahian, J.  Providers, patient-safety advocates brainstorm on decreasing errors, bad attitudes.  Modern Healthcare. 38(49):26-28, Dec. 2008.

Largest patient-satisfaction measurement firms ranked by total number of engagements in 2007.  Modern Healthcare.  38(49):32, Dec. 2008.

Bar-code medication administration: a systems perspective.  American Journal of Health System Pharmacy. 65(23): 2216-2219, Dec. 2008.

In an area where decimal-point medication errors can be fatal, smart infusion pumps are adding a line of defense. Healthcare Informatics.  25(12):20, Dec. 2008.

Gamble, K. No sponge left behind. Healthcare Informatics 25(12):34-39, Dec. 2008.

New sentinel event alert addresses blood thinners.  Healthcare Benchmarks and Quality Improvement.   15(12):128-130, Dec. 2008.

Wristband standardization:  Why we aren't there yet.  Healthcare Benchmarks and Quality Improvement.   15(12):131-132, Dec. 2008.

Infection control.  Zeroing in on infection prevention and control.  Health Facilities Management.  21(12):12-18, Dec. 2008.

Frankel, A., and others.  Revealing and resolving patient safety defects:  the impact of leadership walkrounds on frontline caregiver assessments of patient safety.  Health Services Research.  43(6):2050-2066, Dec. 2008.

Magid, D., and others. The safety of emergency care systems:  results of a survey of clinicians in 65 US emergency departments.  Annals of Emergency Medicine.  Published Online.  Dec. 2008.

Russo, A., Steiner, C., and Spector, W.  Hospitalizations Related to Pressure Ulcers Among Adults 18 Years and Older, 2006.  Rockville, MD:  Agency for Healthcare Research and Quality, Dec. 2008.

Encinosa, W., Hellinger, F.  The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patientsHealth Services Research.  43(6):2067-2085, Dec. 2008.

Hospitals discuss their efforts to reduce surgical site infectionRisk Management Reporter.  27(6):1-24, Dec. 2008.

McDonald, M., and others.  Exploring diabetic care deficiencies and adverse events in home healthcare.  Journal for Healthcare Quality.  30(6):5-12, Nov./Dec. 2008.

Krause, T., and Hidley, J.  Five ways to think about patient safety.  Trustee.  61(10):24-26, 36, Nov./Dec. 2008.

Miller, J.  Tutorial on monitoring time to next medication error:  A response.  Management in Health Care.  17(4):349-352, Oct./Dec. 2008.

Chu, D., and others.  The impact of SARS on hospital performanceBMC Health Services Research.  8:228, Nov. 6, 2008.

Brown, J., editor.  Blue Cross plans, providers work to develop "never-events' policiesAIS Health.com.  Nov. 3, 2008.

Brilli, R., and others.  The business case for preventing ventilator associated pneumoniain pediatric intensive care unit patients. The Joint Commission Journal on Qualityand Patient Safety.  34(11): 629-638, Nov. 2008.

Bonello, R., and others.  An intensive care unit quality improvement collaborative in nine department of Veterans Affairs Hospitals.  The Joint Commission Journal on Quality and Patient Safety. 34(11): 639-645, Nov. 2008.

Herrin, J., Nicewander,D., and Ballard, D.,  The effect of health care system administrator pay for performance on quality of care.  The Joint Commission Journal on Quality and Patient Safety.  34(11): 646-653, Nov. 2008.

Takata, G., Taketomo, C., and Waite S.,  Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.  American Journal of Health System Pharmacy. 65(21): 2036-2044, Nov. 2008.

Wortman, S.,  Medication reconciliation in a community nonteaching hospital.  American Journal of Health System Pharmacy.  65(21): 2047-2054, Nov. 2008.

McKinley, K., and others.  Clinical Microsystems, part 4 building innovative population specific mesosystems. The Joint Commission Journal on Quality and Patient Safety.  34(11): 655-662, Nov. 2008.

Haslinger, T.,  Munson Medical Center embedding a culture of safety and QI into the organization.  The Joint Commission Journal on Quality and Patient Safety.  34(11): 665-670, Nov. 2008.

Strong, D., Kin, J., and Kratochwill, E.  University of Michigan: quality and safety in an Academic Medical Center. The Joint Commission Journal on Quality and Patient Safety.  34(11): 671-677, Nov. 2008.

Ginde, A., and others.  Positive predictive value of ICD-9-CM codes to detect acute exacerbation of COPD in the emergency department.  The Joint Commission Journal on Quality and Patient Safety.  34(11): 678-680, Nov. 2008.

New survey assesses patient safety SNF-specific instrument gets staff feedback on safety culture.  Provider.  34(11):14, Nov.2008.

Preventing falls among older populations: creating a community education program.  Joint Commission Perspectives on Patient Safety. 8(11): 1, 3-4, Nov. 2008.

Addressing substance abuse among health care professionals.  Joint Commission Perspectives on Patient Safety. 8(11): 5-7, Nov. 2008.

Psychiatric polypharmacy: identifying risks and seeking solutions.  Joint Commission Perspectives on Patient Safety. 8(11):8-10, Nov. 2008.

Tricoles, R.  Eliminate errors advanced automation and increased communication are fundamental to cutting down medication mistakes.  The Hospitalist. 12(11): 34-36, Nov. 2008.

Debriefing process can strengthen process for critical incidents. Healthcare Benchmarks and Quality Improvement. 15 (11): 109-111, Nov. 2008.

AHRQ director: We are not doing enough’ on quality. Healthcare Benchmarks and Quality Improvement. 15 (11): 111-113, Nov. 2008.

Antibiotic stewardship programs curb resistance. Healthcare Benchmarks and Quality Improvement. 15 (11): 114-115, Nov. 2008.

Reversing the trend of resistant infections.  Healthcare Benchmarks and Quality Improvement. 15 (11): 117-118, Nov. 2008.

Oversight group holds RCA teams accountable.  Healthcare Benchmarks and Quality Improvement. 15 (11): 115-117, Nov. 2008.

Improving surgical outcomes with data tool.  Healthcare Benchmarks and Quality Improvement. 15 (11): 118-119, Nov. 2008.

Do no harm. AHIP Coverage. 49(6): 25, Nov.2008.

Rubinstein, H., Health care stakeholders overwhelmingly unite around safety incentives as a means to prevent medical errors. AHIP Coverage. 49(6):34-41 , Nov.2008.

Rabinowitz, E. Preventing the preventable. AHIP Coverage. 49(6):26-32, Nov.2008.

The Joint Commission and national quality forum announce the 2008 John M. Eisenberg patient safety and quality awards.  The Joint Commission Perspectives. 28(11): 10-11, Nov. 2008.

Preventing errors relating to commonly used anticoagulants.  The Joint Commission Perspectives. 28(11): 13-15, Nov. 2008.

Runy, L.,A.  The nurse and patient safety.  Hospitals & Health Networks. 82(11):43-50, Nov. 2008.

Brilli, R., and others.  The business case for preventing ventilator associated pneumoniain pediatric intensive care unit patients. The Joint Commission Journal on Qualityand Patient Safety.  34(11): 629-638, Nov. 2008.

Bonello, R., and others.  An intensive care unit quality improvement collaborative in nine department of Veterans Affairs Hospitals.  Joint Commission Journal on Quality and Patient Safety.  34(11): 639-645, Nov. 2008.

Herrin, J., Nicewander,D., and Ballard, D.,  The effect of health care system administrator pay for performance on quality of care.  Joint Commission Journal on Quality and Patient Safety.  34(11): 646-653, Nov. 2008.

Takata, G., Taketomo, C., and Waite S.,  Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.  American Journal of Health System Pharmacy.  65(21): 2036-2044, Nov. 2008.

Wortman, S.,  Medication reconciliation in a community nonteaching hospital. American Journal of Health System Pharmacy.  65(21): 2047-2054, Nov. 2008.

McKinley, K., and others.  Clinical Microsystems, part 4 building innovative population specific mesosystems. Joint Commission Journal on Quality and Patient Safety.  34(11): 655-662, Nov. 2008.

Haslinger, T.,  Munson Medical Center embedding a culture of safety and QI into the organization.  Joint Commission Journal on Quality and Patient Safety.  34(11): 665-670, Nov. 2008.

Strong, D., Kin, J., and Kratochwill, E.  University of Michigan: quality and safety in an Academic Medical Center. Joint Commission Journal on Quality and Patient Safety.  34(11): 671-677, Nov. 2008.

Ginde, A., and others.  Positive predictive value of ICD-9-CM codes to detect acute exacerbation of COPD in the emergency department.  Joint Commission Journal on Quality and Patient Safety.  34(11): 678-680, Nov. 2008.

New survey assesses patient safety SNF-specific instrument gets staff feedback on safety culture.  Provider.  34(11):14, Nov.2008.

Preventing falls among older populations: creating a community education program.  Joint Commission Perspectives on Patient Safety.  8(11): 1, 3-4, Nov. 2008.

Addressing substance abuse among health care professionals.  Joint Commission Perspectives on Patient Safety. 8(11): 5-7, Nov. 2008.

Psychiatric polypharmacy: identifying risks and seeking solutions.  Joint Commission Perspectives on Patient Safety. 8(11):8-10, Nov. 2008.

Tricoles, R.  Eliminate errors advanced automation and increased communication are fundamental to cutting down medication mistakes.  Hospitalist. 12(11): 34-36, Nov. 2008.

Debriefing process can strengthen process for critical incidents. Healthcare Benchmarks and Quality Improvement. 15 (11): 109-111, Nov. 2008.

AHRQ director: We are not doing enough’ on quality. Healthcare Benchmarks and Quality Improvement. 15 (11): 111-113, Nov. 2008.

Antibiotic stewardship programs curb resistance. Healthcare Benchmarks and Quality Improvement. 15 (11): 114-115, Nov. 2008.

Reversing the trend of resistant infections.  Healthcare Benchmarks and Quality Improvement. 15 (11): 117-118, Nov. 2008.

Oversight group holds RCA teams accountable.  Healthcare Benchmarks and Quality Improvement. 15 (11): 115-117, Nov. 2008.

Improving surgical outcomes with data tool.  Healthcare Benchmarks and Quality Improvement. 15 (11): 118-119, Nov. 2008.

Do no harm. AHIP Coverage. 49(6): 25, Nov. 2008.

Rubinstein, H., Health care stakeholders overwhelmingly unite around safety incentives as a means to prevent medical errors. AHIP Coverage. 49(6):34-41 , Nov. 2008.

Rabinowitz, E. Preventing the preventable. AHIP Coverage. 49(6):26-32, Nov .2008.

Joint Commission and national quality forum announce the 2008.  John M. Eisenberg patient safety and quality awards.  Joint Commission Perspectives. 28(11): 10-11, Nov. 2008.

Preventing errors relating to commonly used anticoagulants.  Joint Commission Perspectives. 28(11): 13-15, Nov. 2008.

Runy, L.,A.  The nurse and patient safety.  Hospitals and Health Networks. 82(11):43-50, Nov. 2008.

Barach, P.  The impact of environmental design on patient falls.  Healthcare Design.  8(11):64-70, Nov. 2008.

Diaz, L.  Nursing peer review.  Journal of Nursing Administration.  38(11):475-479, Nov. 2008.

Berwick, D.  Mixed signals.  Materials Management in Health Care. 17(11):15-17, Nov. 2008.

DiConsiglio, J.  Technology can help cut risk of retained items in surgical patients.  Materials Management in Health Care. 17(11):18-21, Nov. 2008.

Birk, S.  Best practices target pressure ulcers.  Materials Management in Health Care. 17(11):32-34, Nov. 2008.

National Priorities and Goals.  Washington:  National Quality Forum, Nov. 2008.

Beck, M.  Beside manner:  advocating for a relative in the hospital.  Wall Street Journal.  Oct. 28, 2008.

ISMP's Second Quarter Watch Report Shows Sharp Increase in Reports of Serious Adverse Drug Events.  Institute for Safe Medication Practices, Oct. 23, 2008.

Raleigh, V., and others.  Patient Safety Indicators for England form hospital administrative data: case-control analysis and comparision with US data.  London, UK:  BMJ Publishing, Oct. 17, 2008.

2008 Update on Consumers' Views of Patient Safety and Quality Information.  Menlo Park, CA:  Henry J. Kaiser Family Foundation, Oct. 15, 2008.

Czark, G., and Mattys, A.  The Compendium of Strategies to Prevent Health-Care Associated Infections in Acute Care Hospitals.  Arlington, VA:  Society for Healthcare Epidemiology of America (SHEA), Oct. 8, 2008.

Kitch, B., and others. Handoffs causing patient harm a survey of medical and surgical house staff.  The Joint Commission Journal on Quality and Patient Safety.  34(10): 563-569, Oct. 2008.

Fowler, F., and others.  Adverse events during hospitalization results of a patient survey.    The Joint Commission Journal on Quality and Patient Safety.  34(10): 583-590, Oct. 2008.

Marsteller, J., and others.  Developing process support tools for patient safety finding the balance between validity and feasibility.  The Joint Commission Journal on Quality and Patient Safety.  34(10): 604-606, Oct. 2008.

Lubomski, L., and others.  The team checkup tool evaluating QI team activities and giving feedback to senior leaders.  The Joint Commission Journal on Quality and Patient Safety.  34(10): 619-622, Oct. 2008.

Schwartz, J., and others.  The daily goals communication sheet a simple and novel tool for improved communication and care.  The Joint Commission Journal on Quality and Patient Safety.  34(10): 608-613, Oct. 2008.

Sattinger, A.M.  Patients’ circumstances count in care planning delve deeper in patient Stories to avoid clinical errors. The Hospitalist. 12(10): 25-27, Oct. 2008.

Pope, C.,  Assessing body systems on admission is critical the act of pressure ulcer prevention.  Material Management in Health Care. 17(10): 18-22, Oct. 2008.

Pear, S.  Infection control hotline prevent VAP with the right tools. Material Management in Health Care. 17(10): 34-36, Oct. 2008.

Kitch, B., and others. Handoffs causing patient harm a survey of medical and surgical house staff.  Joint Commission Journal on Quality and Patient Safety.  34(10): 563-569, Oct. 2008.

Fowler, F., and others.  Adverse events during hospitalization results of a patient survey.  Joint Commission Journal on Quality and Patient Safety.  34(10): 583-590, Oct. 2008.

Marsteller, J., and others.  Developing process support tools for patient safety finding the balance between validity and feasibility.  Joint Commission Journal on Quality and Patient Safety.  34(10): 604-606, Oct. 2008.

Lubomski, L., and others.  The team checkup tool evaluating QI team activities and giving feedback to senior leaders.  Joint Commission Journal on Quality and Patient Safety.  34(10): 619-622, Oct. 2008.

Schwartz, J., and others.  The daily goals communication sheet a simple and novel tool for improved communication and care.  Joint Commission Journal on Quality and Patient Safety.  34(10): 608-613, Oct. 2008.

Sattinger, A.M.  Patients’ circumstances count in care planning delve deeper in patient stories to avoid clinical errors.  Hospitalist. 12(10): 25-27, Oct. 2008.

Pope, C.,  Assessing body systems on admission is critical the act of pressure ulcer prevention.  Material Management in Health Care.  17(10): 18-22, Oct. 2008.

Pear, S.  Infection control hotline prevent VAP with the right tools. Material Management in Health Care. 17(10): 34-36, Oct. 2008.

Targeting safer surgery:  Updates to the universal protocol:  An interview with Peter Angood, M.D., F.C.C.M.  Joint Commission Perspectives on Patient Safety.  8(10):1, 3-4, 8, Oct. 2008.

Singh, N., Brennan, P., and Bell, M.  Editorial: Primum non nocereInfection Control and Hospital Epidemiology. 29(1):1-2, Oct. 2008.  [FREE]

Yokoe, D., and Classen, D.  Introduction: Improving patient safety through infection control: A new healthcare imperativeInfection Control and Hospital Epidemiology. 29(1):1.9, Oct. 2008.  [FREE]

Yokoe, D., and others.  Executive Summary: A Compendium of Strategies to Prevent Healthcare Associated Infection in Acute Care HospitalsInfection Control and Hospital Epidemiology. 29(1):1-10, Oct. 2008.  [FREE]

Marschall, J., and others.  Strategies to prevent central line-associated bloodstream infections in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-9, Oct. 2008.  [FREE]

Coffin, S., and others.  Strategies to prevent ventilator-associated pneumonia in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-9, Oct. 2008.  [FREE]

Lo, E., and others.  Strategies to prevent catheter-associated urinary tract infections in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-10, Oct. 2008.  [FREE]

Anderson, D., and others.  Strategies to prevent surgical site infections in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-11, Oct. 2008.  [FREE]

Calfee, D., and others.  Strategies to prevent transmission of methicillin-resistant staphylococcus aureus in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-19, Oct. 2008.  [FREE]

Dubberke, E., and others.  Strategies to prevent clostridium difficile infections in acute care hospitalsInfection Control and Hospital Epidemiology. 29(1):1-12, Oct. 2008.  [FREE]

To Err Is Human—But Don't Expect to Get Paid For It. ASQ Quarterly Quality Report.  Milwaukee, WI: American Society of Quality; Oct. 2008.

Transforming Care at the Bedside.  Princeton, NJ:  Robert Wood Johnson Foundation, Oct. 2008.

A Clinician's Guide to Electronic Prescribing.  Washington:  eHealth Initiative (eHI), Oct. 2008.

Millote, T.  Successfully protecting against infection during hospital renovations.  Facility Care.   13(7):34-35, Oct. 2008.

Amusan, A., and others.  Time-saver.  A time-motion study to evaluate the impact of EMR and CPOE implementation on physician efficiency.  Journal of Healthcare Information Management.  22(4):31-37, Fall 2008.

Aloisio, J.  Maximizing patient safety utilizing effective patient identification and image labeling practices.  Radiology Management.  30(5):54-59, Sept./Oct. 2008.

Townsend, D.  Signing off.  Effective signs can create a safe environment at healthcare facilities.  Healthcare Construction and Operations News.  6(5):12, Sept./Oct. 2008.

Clancy, C.  New patient safety organizations can help health providers learn from, reduce medical errors.  Patient Safety and Quality Healthcare.  5(5):6-8, Sept./Oct. 2008.

Harden, S.  Creating and sustaining a culture of safety.  Patient Safety and Quality Healthcare.  5(5):12-14, Sept./Oct. 2008.

Metzger, J., and others.  Effective use of medication-related decision support in CPOE.  Patient Safety and Quality Healthcare.  5(5):16-24, Sept./Oct. 2008.

Berger, P., and Sanders, G.  Objects retained during surgery:  human diligence meets systems solutions.  Patient Safety and Quality Healthcare.  5(5):38-42, Sept./Oct. 2008.

A Three-part approach to patient safety.  Healthcare Executive.  23(5):70-74, Sept./Oct. 2008.

Waiting room death brings scrutiny of staff training, attitude. Healthcare Risk Management. 30(9):97-98, Sept. 2008.

Stepnick, L., and others.  2008 Annual national patient safety foundation congress: conference proceedings.  Journal of Patient Safety. 4(3): 129-140, Sept. 2008.

Adams, S., Brodie, A., and Vincent, C.  Safety skills for clinicians: an essential component of patient safety.  Journal of Patient Safety. 4(3): 141-147, Sept. 2008.

Denham, C., and others.  Are you listening. are you really listening? Journal of Patient Safety. 4(3): 148-161, Sept. 2008.

Elder, N., and others.  Nurses’ perceptions of error communication and reporting in the intensive care unit. Journal of Patient Safety. 4(3): 162-168, Sept. 2008.                                                                                 

Classen, D., and others.  Development and evaluation of the institute for healthcare improvement global trigger tool. Journal of Patient Safety. 4(3): 169-177, Sept. 2008.

Chelly, J., and others.  Risk factors and injury associated with falls in elderly hospitalized patients in a community hospital.  Journal of Patient Safety. 4(3): 178-183, Sept. 2008.

Ferranti, J., and others.  A multifaceted approach to safety: the synergistic detection of adverse drug events in adults inpatients.  Journal of Patient Safety. 4(3): 184-190, Sept. 2008.

Sharma, A., and others.  Incident reporting in surgical trainees- revisited.  Journal of Patient Safety. 4(3): 191-194, Sept. 2008.

Mertens, W., and others.  Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight.  Journal of Patient Safety. 4(3): 195-200, Sept.2008.

Denham, C.  CEOs: meet your new revenue preservation officer  Your PSO.  Journal of Patient Safety. 4(3): 201-211, Sept. 2008.

Waiting room death brings scrutiny of staff training, attitude. Healthcare Risk Management. 30(9):97-98, Sept. 2008.

Stepnick, L., and others.  2008 Annual national patient safety foundation congress:  conference proceedings.  Journal of Patient Safety. 4(3): 129-140, Sept. 2008.

Adams, S., Brodie, A., and Vincent, C.  Safety skills for clinicians: an essential component of patient safety.  Journal of Patient Safety. 4(3): 141-147, Sept. 2008.

Denham, C., and others.  Are you listening. are you really listening? Journal of Patient Safety. 4(3): 148-161, Sept. 2008.

Elder, N., and others.  Nurses’ perceptions of error communication and reporting in the intensive care unit. Journal of Patient Safety. 4(3): 162-168, Sept. 2008.                                                                                 

Classen, D., and others.  Development and evaluation of the institute for healthcare improvement global trigger tool. Journal of Patient Safety. 4(3): 169-177, Sept. 2008.

Chelly, J., and others.  Risk factors and injury associated with falls in elderly hospitalized patients in a community hospital.  Journal of Patient Safety. 4(3): 178-183, Sept. 2008.

Ferranti, J., and others.  A multifaceted approach to safety: the synergistic detection of adverse drug events in adults inpatients.  Journal of Patient Safety. 4(3): 184-190, Sept. 2008.

Sharma, A., and others.  Incident reporting in surgical trainees- revisited.  Journal of Patient Safety. 4(3): 191-194, Sept. 2008.

Mertens, W., and others.  Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight.  Journal of Patient Safety. 4(3): 195-200, Sept.2008.

Denham, C.  CEOs: meet your new revenue preservation officer your PSO.  Journal of Patient Safety. 4(3): 201-211, Sept.2008.

Berner, B.  Ethical and legal issues in the use of health information technology to improve patient safety.  HEC Forum.  20(3):243-258, Sept. 2008.

Fuji, K., and Galt, K.  Pharmacists and health information technology:  emerging issues in patient safety.  HEC Forum.  20(3):259-275, Sept. 2008.

Health-Care Associated Infections in Hospitals.  Washington: United States Government Accountability Office, Sept. 2008.

Waxman, C., and Davis, T.   Survey of State Hospital Associations: Practices to Prevent Hospital-Associated Bloodstream Infections.  Washington:  U. S. House of Representatives, Sept. 2008.

Lindberg, L., Judd, K., and Snyder, J.   Developing a safety culture with front-line staffH&HN.  Hospitals & Health Networks.   82(9):84-85, Sept. 2008.

Sakowski, J., Newman, J., and Dozier, K.  Severity of medication administration errors detected by a bar-code medication administration system.  American Journal of Health-System Pharmacy.  65(17):1661-1666, Sept. 1, 2008.

Kaldy, J.   We can do this betterProvider.   34(9):22-35, Sept. 2008.

Getting the whole team on board to prevent retained foreign bodies.  OR Manager.  24(9):1, 15-18, Sept. 2008.

What ORs can learn from the cockpit.  OR Manager.  24(9):5, Sept. 2008.

More surgical infections on no-pay list.  OR Manager.  24(9):7, Sept. 2008.

What works for teamwork training.  OR Manager.  24(9):22, Sept. 2008.

Schneck, L.  Rx to protect your patients.  MGMA Connexion.  8(8):31-32, Sept. 2008.

Stock, R.  Partner with patients for medication safety.  MGMA Connexion.  8(8):35-37, Sept. 2008.

Eliminating transfusion errors related to patient misidentification:  complying with NPSG.01.03.01.  Joint Commission Perspectives on Patient Safety.  8(9):1, 3-4, Sept. 2008.

Advantages and disadvantages of bar code and radio frequency technologies.    Joint Commission Perspectives on Patient Safety.  8(9):5, Sept. 2008.

Preventing surgical site infections (SSI).  Joint Commission Perspectives on Patient Safety.  8(9):8-9, 11 Sept. 2008.

Educating patients about infection control:  complying with NPSG.13.01.01.  Joint Commission Perspectives on Patient Safety.  8(9):10-11, Sept. 2008.

Rollins, G.  A Goal unrealized:  hand hygiene compliance.  Trustee.  61(8):35-36, Sept. 2008.

Soule, B.  Avoiding the drama of health care-associated infections.  Trustee.  61(8):38-40, Sept. 2008.

Majority of emergency patients don't understand discharge instructions.  ED Management.  20(9):97-98, Sept. 2008.

Bohenek, W., and Grossbart, S.  Pharmacists' role in improving quality of care.  American Journal of Health-System Pharmacy.  65(16):1566-1570, Aug. 15, 2008.

Carroll, J.  Payers struggle to find approach to never events.  Managed Care.  17(8):6-7, Aug. 2008.

Hospital cuts injuries with 'falls cart'.  Healthcare Risk Management.  30(8):91-92, Aug. 2008.

2009 safety goals address site marking.  Healthcare Risk Management.  30(8):94-95, Aug. 2008.

Sower, V., Duffy, J., and Kohers, G.   Great Ormond Street Hospital for Children: Ferrari's Formula One Handovers and Handovers From Surgery to Intensive Care.  Milwaukee, WI:  The American Society for Quality, Aug. 2008.  [free registration required].

Incentives for patient safety: holding healthcare executives accountableRisk Management Reporter.  27(4):1-12, Aug. 2008.

2009 national patient safety goal:  the official, approved goals and helpful solutions for meeting them.  Joint Commission Perspectives on Patient Safety.  8(8):1-2, Aug. 2008.

Summary of changes to the national patient safety goals.  Joint Commission Perspectives on Patient Safety.  8(8):3-7, 11, Aug. 2008.

2009 national patient safety goals, requirements, and rationales.  Joint Commission Perspectives on Patient Safety.  8(8):8-11, Aug. 2008.

Hartmann, C., and others.  An overview of patient safety climate in the VA.  Health Services Research.  43(4):1263-1284, Aug. 2008.

Greenberg, C.  The frequency and significance of discrepancies in the surgical count. Annals of Surgery.  248(2):337-341, Aug. 2008.

Bar codes help improve safety in operating room.  Healthcare Benchmarks and Quality Improvement.  15(8):77-78, Aug. 2008.

Study is first to show RRTs decrease pediatric deaths.  Healthcare Benchmarks and Quality Improvement.  15(8):80-83, Aug. 2008.

Admi, H., and others.  Shift work in nursing:  is it really a risk factor for nurses' health and patients' safety?  Nursing Economics.  26(4):250-257, Aug. 2008.

Pearson, S., and others.  The impact of pay-for-performance on health care quality in Massachusetts, 2001-2003.  HealthAffairs.  27(4):1167-1176, July/Aug. 2008.

Harrison, D.  Making patient safety the standard.  Supply Chain Strategies and Solutions.  2(4):6-7, July/Aug. 2008.

Institute for Healthcare Improvement.  Healthcare Executive.  23(4):62, 64, 66, July/Aug. 2008.

Kaiser, D.  Safe and sound.  Healthcare Design.  8(7):22-28, July 2008.

Malkin, J.  The Built environment as a risk factor for infection.  Healthcare Design.  8(7):38-42, July 2008.

Labeling medications in the operating room:  strategies for complying with NPSG.03.04.01.  Joint Commission Perspectives on Patient Safety.  8(7):9-10, July 2008.

Cantrell, S.  Infection connection hunting down HAI: automated tracking technology.  Healthcare Purchasing News.  32(7):32, 36, 38, July 2008.

O'Reilly, K.  National safety effort targets perinatal injuries.  American Medical News.  51(23):8-9, June 16, 2008.

Wilson, L.  The cost of errors.  Modern Healthcare.  (Suppl.):8-9, June 2, 2008.

Wrong-site surgery:  we're not doing all that we can.  Healthcare Benchmarks and Quality Improvement.   15(6):49-52, June 2008.

SHEA estimates preventable HAIs.  Healthcare Benchmarks and Quality Improvement.   15(6):55-56, June 2008.

Kelley, L.  How to win the MDRO battle.  Materials Management in Health Care.  17(6):34-36, June 2008.

Briefing head off communication failures.   OR Manager.  24(6):17-18, June 2008.

Pennsylvania Patient Safety Authority.   Care at Discharge – A Critical Juncture for Transition to Posthospital Care. Pennsylvania Patient Safety Advisory, June 2008. 

Mathias, J.  Mediastinitis:  targeting zero infections.  OR Manager.  24(6):20-21, June 2008.

Allison, J., and others.  Identifying top-performance hospitals by algorithm:  results form a demonstration project.  Joint Commission Journal on Quality and Patient Safety.  34(6):309-317, June 2008.

Jha, A., and others.  Does the Leapfrog program help identify high-quality hospitals?  Joint Commission Journal on Quality and Patient Safety.  34(6):318-325, June 2008.

Hines, S., and Joshi, M.  Variation in quality of care within health systems.  Joint Commission Journal on Quality and Patient Safety.  34(6):326-332, June 2008.

Salas, E., and others.  Communicating, coordinating, and cooperating when lives depend on it:  tips for teamwork.  Joint Commission Journal on Quality and Patient Safety.  34(6):333-341, June 2008.

Pronovost, P., and others.  Paying the piper:  investing in infrastructure for patient safety.  Joint Commission Journal on Quality and Patient Safety.  34(6):342-348, June 2008.

Kass, N., and others.  Controversy and quality improvement:  lingering questions about ethics, oversight, and patient safety research.  Joint Commission Journal on Quality and Patient Safety.  34(6):349-353, June 2008.

Russo, C., Andrews, R., and Barrett, M.   Racial and Ethnic Disparities in Hospital Patient Safety Events, 2005.  Rockville, MD:  Agency for Healthcare Research and Quality, June 2008.

Pinakiewicz, D., and others.  Third annual nursing leadership congress "designing frameworks for patient safety" conference proceedings.  Journal of Patient Safety.  4(2):54-60, June 2008.

Mark, B., and others.  Exploring organizational context and structure as predictors of medication errors and patient falls. Journal of Patient Safety.  4(2):66-77, June 2008.

Sine, D., and Northcutt, N.  Interactive qualitative assessment of patient safety culture survey scores.  Journal of Patient Safety.  4(2):78-83, June 2008.

Herzer, K., and others.  Designing and implementing a comprehensive quality and patient safety management model:  a paradigm for perioperative improvement.  Journal of Patient Safety.  4(2):84-92, June 2008.

Kane, J., Brannen, M., and Kern, E.  Impact of patient safety mandates on medical education in the United States.  Journal of Patient Safety.  4(2):93-97, June 2008.

Zimmer, K., and others.  Electronic narcotic prescription writer:  use in medical error reduction.  Journal of Patient Safety.  4(2):98-105, June 2008.

Elder, N., and others.  Educating seniors to be patient safety self-advocates in primary care.  Journal of Patient Safety.  4(2):106-112, June 2008.

Sheth, H., and others.  Adverse events related to lorazepam use on medical floors.  Journal of Patient Safety.  4(2):61-66, June 2008.

Award-winning program slashes sepsis mortalities.  ED Management.  20(6):64-67, June 2008

Edwards, P., and others.  Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital system.  Journal of Patient Safety.  4(2):113-118, June 2008.

Pediatric medication errors:  using the national patient safety goals to protect patients.  Joint Commission Perspectives on Patient Safety.  8(6):1, 3-5, June 2008.

Creatiing a backup system:  ensuring timely reports of critical test results and values.  Joint Commission Perspectives on Patient Safety.  8(6):6-8, June 2008.

'Smart rooms' help staff, patients.  Health Facilities Management.  21(6):6, June 2008.

Eagle, A.  Safety by [design].  Health Facilities Management.  21(6):30-33, June 2008

Approved:  adverse event reporting for New York office-based surgery practices.  Joint Commission Perpectives.  28(6):7, June 2008.

Lawrence, D.  Closing the loop. Healthcare Informatics.  25(6):90-91, June 2008.

N.Y. Gov. Paterson proposes legislation to improve patient safety.  Medical Liability Monitor.  33(6):1, 7, June 2008.

Coping with safety crisis.  Healthcare IT News.  5(6):1, 14, June 2008.

Garman, L.   MRSA Pace of Progress Report.  Washington: Association for Professionals in Infection Control and Epidemiology, June 2008.

Kronman, M., and others.  Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children's hospitalsPediatrics.  121(6):e1653-e1659, June 2008 .

The Color of Safety, Color Coded Alert Standardization.  Madison, WI:  Wisconsin Hospital Association, June 2008.

Banding Together for Patient Safety.  Implementation Tool Kit.  Harrisburg, PA:  Hospital and Healthsystem Association of Pennsylvania, June 2008.

Webster, T., and others.  Organizational resiliency:  how top-performing hospitals respond to setbacks in improving quality of cardiac care.  Journal of Healthcare Management.  53(3):169-182, May/June 2008.

Safety buzz prompts new campaign.  Healthcare Advertising Review.  24(3):8-10, May/June 2008.

Kolovos, N., Bratton, S., and Levy, F.  A novel error-reporting tool in pediatric intensive care.  Journal for Healthcare Quality.  30(3):43-50, May/June 2008 .

Furukawa, M., and others.  Adoption of health information technology for medication safety in U.S. hospitals, 2006.  Health Affairs.  27(3):865-875, May/June 2008.

Hoff, T.  How work context shapes physician approach to safety and error.  Quality Management in Health Care.  17(2):140-153, Apr./June 2008.

Runy, L.   Pharmacy automationH & HN's.  7(2):14-20, Spring 2008.

Joch, A.   Second in commandH & HN'sWeb Excclusive.  Spring 2008.

Landro, L.  Hospitals move to reduce risk of night shift. Wall Street JournalWeb Exclusive.  May 28, 2008.

Pronovost, P., Goeschel, C., and Wachter, R. The wisdom and justice of not paying for "preventable complications". JAMA (Journal of American Medical Association).  299(18):2197-2199, May 14, 2008.

Gardner, E.  Turning talk into action.  Modern Healthcare.  38(19):28-31, May 12, 2008.

Asghari, F.  Doctor’s views of attitudes towards peer medical error.  Post Graduate Medical Journal. May 10, 2008.

Massoomi, F., and others.  Implementation of a safety program for handling hazardous drugs in a community hospital.  American Journal of Health-System Pharmacy.  65(9):861-865, May 1, 2008.

Patrick, M.  Infection control hotline.  Materials Management in Healthcare.  17(5):34-36, May 2008.

Eash, B.  Infection prevention's role during renovation and construction.  Materials Management in Healthcare.  17(5):48, May 2008.

Santamour, B.  As a superbug spreads, so does misinformation.  H &HN.  Hospitals & Health Networks.  82(5):37-40, May 2008.

Runy, L.  Patient handoffs.  Hospitals and Health Networks.  82(5):41-48, May 2008.

Aiken, L., and others.  Effects of hospital care environment on patient mortality and nurse outcomes.  Journal of Nursing Administration.  38(5):223-229, May 2008.

Dalton, G., Samaropoulos, X., and Dalton, A.  Improvements in the safety of patient care can help end the medical malpractice crisis in the United States.  Health Policy.  86(2-3):153-162, May 2008.

Solberg, L., and others.  Can patient safety be measured by surveys of patient experiences?  Joint Commission Journal on Quality and Patient Safety.  34(5):266-274, May 2008.

Rosen, A., and others.  Recruitment of hospitals for a safety climate study:  facilitators and barriers.    Joint Commission Journal on Quality and Patient Safety.  34(5):275-284, May 2008.

Catching a superbug:  screening inpatients for methicillin-resistant staphylococcus aureus (MRSA).  Joint Commission Perspectives on Patient Safety.  8(5):1, 3-4, May 2008.

International normalized ratio (INR) reporting:  complying with national patient safety goal 3E.  Joint Commission Perspectives on Patient Safety.  8(5):5-6, 11, May 2008.

Preventing catheter-related bloodstream infections. Joint Commission Perspectives on Patient Safety.  8(5):7-9, May 2008.

Cantrell, S.  Operating Room.  Fanning the flames of surgical fire prevention. Healthcare Purchasing News.  32(5):26-28, May 2008.

Pastorius, D.  Update: 5 million lives campaign.  Nursing Management.  39(5):13-18, May 2008.

Overconfidence as a cause of diagnostic error in medicineAmerican Journal of Medicine.  121(5):S2-S23, May 2008.

'Stunning' CPOE study spurs immediate action in Massachusetts.  Healthcare Benchmarks and Quality Improvement.  15(5):37-40, May 2008.

Dalton, G., Samaropoulos, X., and Dalton, A.  Improvements in the safety of patient care can help end the medical malpractice crisis in the United StatesHealth Policy.  86(2-3):153-162, May 2008.

MacKenzie, K.  The British have banned below-the-elbow clothing for physicians--but is eliminating white coats and fake fingernails the best way to stop infections?   HealthLeaders Media.  Apr. 23, 2008.

Elixhauser, A., and Jhung, M.   Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993-2005HCUP Statistical Brief 50:1-11, Apr. 2008.

Takata, G., and others.  Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics.  121(4):e927-e935, Apr. 2008.

Betbeze, P.  Patient safety pays. HealthLeaders.  11(4):57, Apr. 2008.

MacReady, N.  Drug misuse varies.  Hospitalist.  12(4):16, 18, Apr. 2008.

Implementing national patient safety goal requirement 3E:  a model plan. Joint Commission Perspectives on Patient Safety.  8(4):1, 3-6, Apr. 2008.

Improving control of concentrated electrolyte solutions.  Joint Commission Perspectives on Patient Safety.   8(4):7-9, Apr. 2008.

Clinical pharmacists seek way to address medication errors.  Joint Commission Perspectives on Patient Safety.  8(4):10-11, Apr. 2008.

Hughes, R., editor. Patient Safety and Quality:An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality, Apr. 2008.

CEO Patient Safety Self-Assessment.  Livonia, MI: Market Strategies International, Apr. 2008.

Rader, R.   Patient- and Family-Centered Care Initiative is Associated With High Patient Satisfaction and Positive Outcomes for Total Joint Replacement Patients.  Rockville, MD:  Agency for Healthcare Research and Quality, Apr. 28, 2008.

Patient Safety Alert:  'Smart rooms' provide patient safety into at the bedside.  Healthcare Benchmarks and Quality Improvement.  15(4):Insert: 1-2, Apr. 2008.

Hand gel fails to curb infections on its own.  Healthcare Benchmarks and Quality Improvement.  15(4):32-33, Apr. 2008.

Joint Commission releases proposed 2009 NPSGs.  Healthcare Benchmarks and Quality Improvement.  15(4):33-35, Apr. 2008.

Thill, L.  The big picture.  Journal of Healthcare Contracting.  5(2):12-16, Mar./Apr. 2008.

Looking for MRSA.  Journal of Healthcare Contracting.  5(2):18, 20, Mar./Apr. 2008.

Frankel, A.  Walkrounds.  Healthcare Executive.  23(2):22-28, Mar./Apr. 2008.

Most Organizations Use Form to Facilitate Handoffs.   Marblehead, MA:  Association for Healthcare Accreditation Professionals, Mar. 27, 2008.

Foster, D.   Trends in Patient Safety Adverse Outcomes and 100 Top Hospitals Performance, 2000-2005.  Ann Arbor, MI:  Thomson Healthcare, Mar. 17, 2008.

2007 Annual Report of Hospital Adverse Events.  Portland, OR:  Oregon Patient Safety Commission, Mar. 11, 2008.

Hansen, D.  Rules aim for better patient safety through confidential error reports.  American Medical News.  51(10):1-2, Mar. 10, 2008.

Hicks, R., and others.  Medication errors involving patient-controlled analgesia.  American Journal of Health-System Pharmacy.  65(5):429-440, Mar. 1, 2008.

Preventing accidents and injuries in the MRI suite.  Joint Commission Perspectives.  28(3):6-8, Mar. 2008.

Khushf, G., Raymond, J., and Beaman, C.  The Institute of Medicine's reports on quality and safety:  paradoxes and tensions.  HEC Forum.  20(1):1-14, Mar. 2008.

Nelson, W., and others.  Collaboration of ethics and patient safety programs:  opportunities to promote quality care.  HEC Forum.  20(1):15-27, Mar. 2008.

Sheridan, S., and others.  Disclosure through our eyes.  Journal of Patient Safety.  4(1):18-26, Mar. 2008.

Sattinger, A.  Safety seminars.   Hospitalist.  12(3):31-34, Mar. 2008.

ORs vary in how they do time-out, and many don't follow own policy.  OR Manager.  24(3):1, 9-10, Mar. 2008.

What's expected for med reconciliation?  OR Manager.  24(3):21-23, Mar. 2008.

Runy, L.  Pharmacists in the ED help reduce errors. H & HN.  Hospitals and Health Network.  82(3):12-14, Mar. 2008.

Medication safety with the use of chemotherapy agents.  Joint Commission Perspectives on Patient Safety.  8(3):1, 4-5, Mar. 2008.

CT scanners:  are 256-slices of radiation worth the risk to patients?  Joint Commission Perspectives on Patient Safety.  8(3):10-11, Mar. 2008.

Health Care Protocol: Prevention of Falls (Acute Care).    Bloomington, MN:  Institute for Clinical Systems Improvement, Mar. 2008.

Goeschel, C.  Monitoring patient safety and quality:  a simple framework. Trustee.  61(3):34-35, Mar. 2008.

Clancy, C.  Forging a new path to medication safety with emergency pharmacists.  Journal of Patient Safety.  4(1):1-2, Mar. 2008.

Salas, E., and others.  Simulation-based training for patient-safety:  10 principles that matter.    Journal of Patient Safety.  4(1):3-8, Mar. 2008.

Blais, R., and others.  Can we use incident reports to detect hospital adverse events?  Journal of Patient Safety.  4(1):9-12, Mar. 2008.

Riley, W., and others.  The Patient Safety and Quality Improvement Act of 2005:  developing an error reporting system to improve patient safety.   Journal of Patient Safety.  4(1):13-17, Mar. 2008.

Sheridan, S., and others.  Disclosure through our eyes.    Journal of Patient Safety.  4(1):18-26, Mar. 2008.

Paterick, T. J., and Paterick, T. E.  Optimizing patient safety when primary care and subspecialty practitioners work in concert to prescribe medications.  Journal of Patient Safety.  4(1):27-30, Mar. 2008.

Bahl, V., and others.  Developing an adverse event reporting system using administrative data.   Journal of Patient Safety.  4(1):31-37, Mar. 2008.

Denhum, C.  SBAR for patients. Journal of Patient Safety.  4(1):38-48, Mar. 2008.

Houchens, R., Elixhauser, A., and Romano, P.  How often are potential patient safety events present on admission?  Joint Commission on Quality and Patient Safety.  34(3):154-163, Mar. 2008.

Ford, E., and Short, J.  The impact of health system membership on patient safety initiatives.  Health Care Management Review.  33(1):13-20, Jan./Mar. 2008.

DerGurahian, J.  Checklist is back...HHS reverses stand, but hospitals still seek answers.  Modern Healthcare.  38(8):8-9, Feb. 25, 2008.

Whelan, D.   How safe are America's hospitals?    Forbes.com Magazine.  Feb. 20, 2008.

Snyder, R.  Hardwiring hand hygience among staff members.  Nursing Management.  39(2):14, Feb. 2008.

Kraus, S., and others.  Implementing computerized physician order management at a Community Hospital.  Joint Commission Journal on Quality and Patient Safety.  34(2):74-84, Feb. 2008.

Tsilimingras, D., and Bates, D.  Addressing postdischarge adverse events:  a neglected area. Joint Commission Journal on Quality and Patient Safety.  34(2):85-97, Feb. 2008.

Wachter, R., Foster, N., and Dudley, R.  Medicare's decision to withhold payment for hospital errors:  the devil is in the details.    Joint Commission Journal on Quality and Patient Safety.  34(2):116-124, Feb. 2008.

Riehle, M., Bergeron, D., and Hyrkas, K.  FMEA and medication administration.    Nursing Management.  39(2):28-33, Feb. 2008.

Michigan's focus on ICU patient safety achieves success.  Risk Management Report.  27(1):1, 3-8, Feb. 2008.

Cantrell, S.  Striving for excellence:  infection-prevention success stories.  Healthcare Purchasing News.   32(2):24-29, Feb. 2008.

Adams, M., and others.   Saving Lives, Saving Money: the Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.  Massachusetts Technology Collaborative and New England Healthcare Institute, Feb. 2008.

Sipkoff, M.  Why is it so tough to deliver on e-prescribings' promise?  Managed Care.  17(2):42-47, Feb. 2008.

Shamliyan, T., and others.  Just what the doctor ordered, review to the evidence of the impact of computerized physician order entry system on medication errors.  Health Services Research.  43(1)Part 1:32-53, Feb. 2008.

West, A., Weeks, W., and Bagian, J.  Rare address medical events in VA inpatient care:  reliability limits to using patient safety indicators as performance measures.  Health Services Research.  43(1)Part 1:249-266, Feb. 2008.

Patient suicide:  complying national patient safety goal 15A.  Joint Commission Perspectives on Patient Safety.  8(2):7-8, 11, Feb. 2008.

Garbutt, J., and others.  Lost opportunities:  how physicians communicate about medical errors.  Health Affairs.  27(1):246-255, Jan./Feb. 2008.

Thielst, C., and Gardner, J.  Clinical documentation systems:  another link between technology and quality.  Journal of Healthcare Management.  53(1):5-7, Jan./Feb. 2008.

Nicholson, D., and Mitchel, L.  A medical error happened:  Now what?  The implications for medical errors heat up.  Journal of Health Care Compliance.  10(1):5-12, Jan./Feb. 2008.

Shortell, S., and Singer, S.  Improving patient safety by taking systems seriously.  JAMAJournal of the American Medical Association.  299(4):445-447, Jan. 30, 2008.

FDA Public Health Notification: Unretrieved Device Fragments.  Washington:  U.S. Food and Drug Administration, Jan. 15, 2008.

Kaldjian, L., and others.   Reporting medical errors to improve patient safetyArchives of Internal Medicine.  168(1):40-46, Jan. 14, 2008.

Door-to-Doc Patient Safety Toolkit.  Phoenix, AZ:  Banner Health, Jan. 14, 2008.

Physicians Want To Learn from Medical Mistakes but Say Current Error-reporting Systems Are Inadequate.  Rockville, MD: Agency for Healthcare Research and Quality, Jan. 9, 2008.

Zhan, C., and others.  How useful are voluntary medication error reports?  Joint Commission Journal on Quality and Patient Safety.  34(1):36-45, Jan. 2008.

Lipshutz, A.  Medication errors associated with code situations in U.S. hospitals:  direct and collateral damage.  Joint Commission Journal on Quality and Patient Safety.  34(1):46-56, Jan. 2008.

The Joint Commission issues improving America's hospitals report.  Joint Commission Perspectives on Patient Safety.  8(1):2, Jan. 2008.

Involving frontline staff in patient safety.  Joint Commission Perspectives on Patient Safety.  8(1):10-11, Jan. 2008.

Safety expert blames poor flow for many errors.  Healthcare Benchmarks and Quality Improvement.  15(1):3, Jan. 2008.

Is 'non-pay for non-performance' a wave of the future of health care?  Healthcare Benchmarks and Quality Improvement.  15(1):1-4, Jan. 2008.

Data for safety:  turning lessons learned into actionable knowledge.  Journal of Healthcare Risk Management.  28(2):7-18, 2008.

Fasler, K.  Integrating disclosure, patient safety and risk management activities.  Journal of Healthcare Risk Management.  28(2):19-25, 2008.

Knight, T.  Becoming a top quality and safety hospital.  Building Quality in Health Care.  2(2):9-10, 2008.

Franca, M.  Quality, risk management and patient safety:  the challenge of effective integration.  World Hospitals and Health Services.  44(4):21-23, 2008.

The Leapfrog Hospital Survey Results 2008.  Washington:  The Leapfrog Group, 2008.

Bagalio, S.  When systems fail:  improving care through technology can create risk.    Journal of Healthcare Risk Management.   27(4):13-18, 2008.

Wachter, R.  Understanding Patient Safety.  New York:  McGraw Hill Medical, 2008.  (WB 100 W114u 2008).

A Guide to Patient Safety in the Medical Practice.  Chicago:  American Medical Association, 2008.  (W 84.1 V222g 2008).

Palmieri, P., Peterson, L., and Ford, E.  Technological iatrogenesis:  new risks force heightened management awareness.  Journal of Healthcare Risk Management.   27(4):19-24, 2008.

Cohen, M.  Medication Use:  A Systems Approach to Reducing Errors.  2nd ed.  Oakbrook Terrace, IL:  Joint Commission Resources, 2008.  (WX 179 M489 2008).

Personett, M.  Modernization of patient safety event reporting:  surveillance and benchmarking.  Journal of Healthcare Risk Management.   27(4):39-43, 2008.

Fleming, M., and Wentzell, N.  Patient safety culture improvement tool:  development and guidelines for use.  Healthcare Quarterly.  11(Spec. 3):10-15, 2008.

Detsy-M., and Etchells, E.  Single-patient rooms for safe patient-centered hospitals.  JAMA.  Journal of the American Medical Association.   300:954-956, 2008.

Zimmerman, R., and others.  An evaluation of patient safety leadership walkarounds.  Healthcare Quarterly.  11(Spec. 3):16-20, 2008.

Tardif, G., and others.  Implementation of a safety framework in a rehabilitation hospital.  Healthcare Quarterly.  11(Spec. 3):21-25, 2008.

McConnell, H., and Pardy, A.  Virtual patient simulation for prevention of medical error:  beyond just technical upskilling.  World Hospitals and Health Services.  44(3):36-39, 2008.

Zimmerman, R., and others.  Developing a patient safety plan.  Healthcare Quarterly.  11(Spec. 3):26-30, 2008.

Rust, T., and others.  Broadening the patient safety agenda to include safety in long-term care.  Healthcare Quarterly.  11(Spec. 3):31-34, 2008.

Neudorf, K., and others.  Nursing education:  a catalyst for the patient safety movement.  Healthcare Quarterly.  11(Spec. 3):35-39, 2008.

Nigam, and others.  Development of Canadian safety indicators for medication use.   Healthcare Quarterly.  11(Spec. 3):47-53, 2008.

Merali, R., and others.  Medication safety in the operating room:  teaming up to improve patient safety. Healthcare Quarterly.  11(Spec. 3):54-57, 2008.

Armutlu, M., and others.  Survey of nursing perceptions of medication administration practices perceived sources of errors and reporting behaviours. Healthcare Quarterly.  11(Spec. 3):58-65, 2008.

White, D., and others.  Communities of practice:  creating opportunities to enhance quality of care and safe practices.  Healthcare Quarterly.  11(Spec. 3):80-84, 2008.

Burns, K.  Canadian patient safety champions:  collaborating on improving patient safety.  Healthcare Quarterly.  11(Spec. 3):95-100, 2008.

Matlow, A., and others.  Improving patient safety through a multi-faceted internal surveillance program.  Healthcare Quarterly.  11(Spec. 3):101-108, 2008.

Dyer, D., and others.  An intervention program to reduce falls for adult in-patients following major lower limb amputation.  Healthcare Quarterly.  11(Spec. 3):117-121, 2008.

Pittet, D.  Transforming health care facilities across the world into hand hygiene excellence centres.  Building Quality in Health Care. 2(1): 6-9, 2008.

Storr, J.  A new way to address an old problem: The who multimodal  hand hygiene improvement strategy.   Building Quality in Health Care. 2(1): 10-13, 2008.

Hawkins, K.  Infection prevention: a methodology for performance improvement.  Building Quality in Health Care.  2(1): 15-17, 2008.

Knight, T., and others.  Reducing central venous catheter infections in the intensive care unit: a multidisciplinary approach.  Building Quality in Health Care. 2(1): 18-20, 2008.

Burland, E.  An evaluation of a fall management program in a personal care home population.  Healthcare Quarterly.  11(Spec. 3):137-140, 2008.

Tackling patient safety taxonomy:  a must for risk managers.  Journal of Healthcare Risk Management.   28(1):7-17, 2008.

High-Alert Medications.  Strategies for Improving Safety.  Oakbrook Terrace, IL:  Joint Commission Resources, 2008.  (WX 179 H634 2008).

Meeting the Joint Commission's 2009 National Patient Safety Goals.  Oakbrook Terrace, IL:  Joint Commission Resources, 2008.  (WX 153 M495 2008).

Medical Team Training:  Strategies for Improving Patient Care and Communication.  Oakbrook Terrace, IL:  Joint Commission Resources, 2008.  (W 84.8 M489 2008).

Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets.  Horsham, PA:  Institute for Safe Medication Practices (ISMP), 2008.

Vries, E., and others.   The incidence and nature of in-hospital adverse events: a systematic reviewQuality and Safety in Health Care.  17(3):216-223, 2008.

Fleming, M., and Wentzell, N.  Patient safety culture improvement tool: development and guidelines for useHealthcare Quarterly.  11(sp):10-15, 2008.

Zimmerman, R., and others.   Creating a patient safety culture: An evaluation of patient safety leadership walkaroundsHealthcare Quarterly.  11(sp):16-20, 2008.

Walsh, K., and others.   Effect of computer order entry on prevention of serious medication errors in hospitalized childrenPediatrics.  121(3):e421-e427, 2008.

Gaétan, T., and others.   Broadening the patient safety agenda: Implementation of a safety framework in a rehabilitation hospital.    Healthcare Quarterly.  11(sp):21-25, 2008.

A Guide to Patient Safety in the Medical Practice.  Chicago:  American Medical Association, 2008.  (W 84.1 V222g 2008).

From the Hospital to all Care Settings: Working Together to Improve Care and Prevent Harm.  Chicago:  American Medical Association, 2008.

Cohen, M.  Medication Use:  A Systems Approach to Reducing Errors.  2nd ed.  Oakbrook Terrace, IL:  Joint Commission Resources, 2008.  (WX 179 M489 2008).

Zimmerman, R., and others.  Developing a patient safety plan .   Healthcare Quarterly.  11(sp):26-30, 2008.

Nance, J.  Why Hospitals Should Fly:  Ultimate Flight Plan to Patient Safety and Quality Care.  Bozeman, MT:  Second River Healthcare Press, 2008. (WX 162 N176w 2008).

Rust, T., and others.  Broadening the patient safety agenda to include safety in long-term careHealthcare Quarterly.  11(sp):31-34, 2008.

Paugh, J.  2009 The National Patient Safety Goals Calculator.  Tools to Assess Compliance.  Marblehead, MA:  HCPro, Inc., 2008.  (WX 153 P323n 2008).

Pittet, D.  Transforming health care facilities across the world into hand hygiene excellence centres.  Building Quality in Health Care. 2(1): 6-9, 2008.

Storr, J.  A new way to address an old problem: The who multimodal  hand hygiene improvement strategy.   Building Quality in Health Care. 2(1): 10-13, 2008.

Hawkins, K.  Infection prevention: a methodology for performance improvement.  Building Quality in Health Care. 2(1): 15-17, 2008.

Knight, T., and others.  Reducing central venous catheter infections in the intensive care unit: a multidisciplinary approach. Building Quality in Health Care.  2(1): 18-20, 2008.

Tackling Patient Safety Taxonomy: A Must for Risk Managers.  Chicago:  American Soceity for Healthcare Risk Management, 2008.

Baretich, M.  Management Monograph Series.  Patient Safety and Facility Management The Role of Healthcare Facilities Engineers.  Chicago:  American Society for Healthcare Engineering, 2008.  (WX 185 B248p 2008).

Hospital Pulse Report 2008.   Patient Perspectives on American Health Care.  South Bend, IN:  Press Ganey, 2008.

Garbutt, J., and others.   Lost opportunities: How physicians communicate about medical errorsHealth Affairs.  27(1):246-255, 2008.

Hicks, R., Becker, S., Cousins, D., editors.  MEDMARX data report. A report on the relationship of drug names and medication errors in response to the Institute of Medicine’s call for action.  Rockville, MD: Center for the Advancement of Patient Safety, US Pharmacopeia, 2008.

 

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