Scanning the Headlines: Patient Safety (Archive) 2009

 
Updated on August 5, 2010

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Comak, H. Virginia Hospital celebrates five years with no VAP eventsHealthLeaders Media.  Dec. 30, 2009.

One MRSA Infection Costs a Hospital $60,000.  New York:  NBC News, Dec. 15, 2009.

Clark, C. CDC video urges patients to insist they witness provider hand-washingHealthLeaders Media.  Dec. 7, 2009.

Sweeney, E.  Two ways to correct safety regulation violatorsHealthLeaders Media.  Dec. 4, 2009.

Shaw, G.  Patient experience: four benefits and five prioritiesHealthLeaders Media.  Dec. 2, 2009.

Wachter, R.  Patient safety at ten: unmistakable progress, troubling gapsHealth Affairs.  29(1):165-173, Dec. 1, 2009.

Bohmer, R. M. J., and others. Restructuring within an academic health center to support quality and safety: the development of the Center for Quality and Safety at the Massachusetts General Hospital. Academic Medicine. 84(12):1663-1671, Dec. 2009.

Patterson, P. Building a strong ASC QI program. OR Manager. 25(12):24-26, Dec. 2009.

Paterick, Z. R., and others. The challenges to transparency in reporting medical errors. Journal of Patient Safety. 5(4):205-209, Dec. 2009.

Denham, C. R., and others. The chasing zero department: making idealized design and reality. Journal of Patient Safety. 5(4):210-215, Dec. 2009.

Edwards, J., and others.  National Healthcare Safety Network (NHSN) Report: Data Summary for 2006 Through 2008.  Washington, DC:  Association for Professional in Infection Control and Epidemiology Inc.  Dec. 2009.

Denham, C. R., and others. Chasing zero: can reality meet the rhetoric? Journal of Patient Safety. 5(4):216-222, Dec. 2009.

Moore, C., and others. Predictive value of alert triggers for identification of developing adverse drug events. Journal of Patient Safety. 5(4):223-228, Dec. 2009.

Henriksen, K., Joseph, A., and  Zayas-Caban, T. The human factors of home health care: a conceptual model for examining safety and quality concerns.  Journal of Patient Safety. 5(4):229-236, Dec. 2009.

Brannen, M. L., and others. Admission handoff communications: clinicians shared understanding of patient severity of illness and problems. Journal of Patient Safety. 5(4):237-242, Dec. 2009.

When comfort has a cold nose: balancing animal-assisted therapy and health care facility infection prevention and control.  Environment of Care News. 12(12,): 4-8, Dec. 2009.

Collecting, sharing data tops list of challenges for quality managers. Healthcare Benchmarks and Quality Improvement. 16(12):133-136, Dec. 2009.

Mahmood, A., Chaudhury, H., and Gaumont, A.  Environmental issues related to medication errors in long-term care:  lessons from the literature.  Health Environmentents Research and Design Journal.  2(2):42-59, Winter 2009.

Gryboski, A., Van Tilburg, J., and Butterick, J. Quality Buckets: an innovative tool for complying with healthcare mandates.  Journal for Healthcare Quality. 31(6):3-7, Nov./Dec. 2009.

Buckley, M., Laursen, J., and Otarola, V. Strengthening physician-nurse partnerships to improve quality and patient safety. Physician Executive. 35(6):24-28, Nov./Dec. 2009.

Singer, S. J., and others. Identifying organizational cultures that promote patient safety. Healthcare Management Review. 34(4):300-311, Oct./Dec. 2009.

Khatri, N., Brown, G.  D., and Hicks, L. L. From a blame culture to a just culture in health care. Healthcare Management Review. 34(4):312-322, Oct./Dec. 2009.

Simmons, J.  The foundation of quality is safetyHealthLeaders Media.  Nov. 19, 2009.

Shanafelt, T., and others.  Burnout and medical errors among American surgeonsAnnals of Surgery.  Nov. 19, 2009.

Setter, S. M., and others. Effectiveness of a pharmacist-nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care. American Journal of Health-System Pharmacy. 66(22):2027-31, Nov. 15, 2009.

Ginzberg, R., and others. Effect of a weight-based prescribing method within an electronic health record on prescribing errors.  American Journal of Health-System Pharmacy. 66(22):2037-41, Nov. 15, 2009.

Comak, H., and Clark, C.  Medical confessional highlights doctors' diagnostic errorsHealthLeaders Media.  Nov. 10, 2009.

Schiff, G., and others.  Diagnostic error in medicineArchives of Internal Medicine.  169(20):1881-1887, Nov. 9, 2009.

FDA’s Safe Use Initiative Collaborating to Reduce Preventable Harm from Medications Safe Use.  Silver Spring, MD:  U.S. Department of Health and Human Services Food and Drug Administration.  Nov. 4, 2009.

2010 top 10 technology hazards. Health Devices. 38(11):1-10, Nov. 2009.

Pingleton, S. K., and others. Is there a relationship between high-quality performance in major teaching hospitals and residents’ knowledge of quality and patient safety? Academic Medicine. 84(11):1510-15, Nov. 2009.

Preventing retained surgical items: what role does technology play? OR Manager. 25(11):1, 8-11, Nov. 2009.

A 4-year effort to prevent retained items. OR Manager. 25(11):12-15 , Nov. 2009.

Ryckman, F. C., and others. Redesigning intensive care unit flow using variability management  to improve access and safety. Joint Commission Journal on Quality and Patient Safety. 35(11):535-543, Nov. 2009.

Chen, L. M., Rein, M. S., and Bates, D. W. Costs of quality improvement: a survey of four acute care hospitals. Joint Commission Journal on Quality and Patient Safety. 35(11):544-550, Nov. 2009.

Simpson, K. R., Kortz, C. C., and  Knox, E. A comprehensive perinatal patient safety program to reduce preventable adverse outcomes and costs of liability claims. Joint Commission Journal on Quality and Patient Safety. 35(11):565-574, Nov. 2009.

What are the biggest risks involving ED handoffs? ED Management. 21(11):128-130, Nov. 2009.

Pati, D., Harvey, T. E., and Ragan, K. S. Patient safety: what enhances patient visibility? Healthcare Design. 9(11):84-90, Nov. 2009.

Connovich, R. Designing for infection prevention. Healthcare Design. 9(11):46-54, Nov. 2009.

Klingner, J., and others. Implementing patient safety initiatives in rural hospitals. Journal of Rural Health. 25(4):352-357, Fall 2009.

Briggs, L., and others. RFID in the blood supply chain. Journal of Health Information Management. 23(4):54-63, Fall 2009.

Sirajuddin, A. M., and others. Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Journal of Health Information Management. 23(4):38-45, Fall 2009.

Dieckhaus, T., Martin, K., and Clark, R. Managing the medication reconciliation process. Journal of Health Information Management. 23(4):34-37, Fall 2009.

McNulty, J, Donnelly, E., and Iorio, K. Methodologies for sustaining barcode medication administration compliance. Journal of Health Information Management. 23(4):30-33, Fall 2009.

Agrawal, A, and Glasser, A R. Barcode medication. Journal of Health Information Management. 23(4):24-29, Fall 2009.

Troiano, D. Safely automating the medication use process. Journal of Health Information Management. 23(4):17-23, Fall 2009.

Lang, R. D. Medication management.  Complexity defined. Journal of Health Information Management. 23(4):2-4, Fall 2009.

Bluni, R., and O’Shaughnessy, J.  Words that save.  Marketing Health Services.  29(3):13-17, Fall 2009.

Comak, H.  Nurses Use Repetitive Processes to Catch Medication ErrorsHealthLeaders Media.  Oct. 30, 2009.

Clark, C.  Feds dole out dollars to fight hospital-acquired MRSAHealthLeaders Media.  Oct. 28, 2009.

Vaughn, C. Five lessons on how to get physicians to adopt CPOE. HealthLeaders Media. Oct. 20, 2009.

Clark, C. Cedars-Sinai CEO suggests CT changes to prevent more radiation overdoses. HealthLeaders Media.  Oct. 16, 2009.

Rothschild, J., and others.  Risks of complications by attending physicians after performing nighttime procedures. JAMA. 302(14):1565-1572, Oct. 14, 2009.

Sweeney, E.  Hospital reduces infection rates quicklyHealthLeaders Media.  Oct. 9, 2009.

Comak, H. Joint commission’s 2010 patient safety goals reduce requirements. Healthleaders Media. Oct. 1, 2009.

Macaulay, T. E., and others. Pharmacists’ role in facilitating evidence-based prescribing for unlabeled use of medications. American Journal of Health-System Pharmacy. 66(19):1735-1739, Oct. 1, 2009.

Ghaferi, A., Birkmeyer, J., and Dimick, J.  Variation in hospital mortality associated with inpatient surgery.  New England Journal of Medicine. 361(14):1368-1375, Oct. 1, 2009.

Liebhaber, A., Draper, D, and Cohen, GHospital Strategies to Engage Physicians in Quality Improvement. Washington, DC: Center for Studying Health System Change, Oct. 2009.

Murphy, A. M., and others. AHLA Connections. 13(10):24-28, Oct. 2009.

10 years, 5 voices, 1 challenge. Hospitals & Health Networks. 83(10):24-28, Oct. 2009.

Aston, G. A Recipe to reduce pressure ulcers. Materials Management in Healthcare. 18(10):30-32, Oct. 2009.

Nutty C. Budget cuts in infection protection. Materials Management in Healthcare. 18(10):34-36, Oct. 2009.

DeJohn, P. Move beyond the lockbox approach; Improving medication safety. Materials Management in Healthcare. 18(10):26-28, Oct. 2009.

Patient safety and elastomeric pumps.  The Joint Commission Perspectives on Patient Safety.  9(10):9-11, Oct. 2009.

Kemper, C., Boos, G., and Moore, C.  Without a trace(r)…your hospital may be at increased risk for a ‘never event.’  The Joint Commission Perspectives on Patient Safety.  9(10):1, 3-6, Oct. 2009.

Singer, S., and others.  Comparing safety climate between two populations of hospitals in the United States.  Health Services Research.  44(5, Part I):1563-1584, Oct. 2009.

Silvaugh, B., and Leider, H.  Physician leadership is key to creating a safer, more reliable health care system. Physician Executive. 35(5):12-16, Sept./Oct. 2009.

Jones, D., and Cotta, J.  Lessons from the field: how one hospital combines quality, compliance, and patient safety.  Journal of Health Care Compliance.  11(5):53-56, Sept./Oct. 2009.

Silveria, L.  Compliance with CMS ‘never event’ billing requirements.  Journal of Health Care Compliance.  11(5):33-36, Sept./Oct. 2009.

Willding, L. Make safety a mission. Alliance.:24-29, Sept./Oct. 2009.

Scarrow, P.K.  Interview with a quality leader: Paul Gluck, immediate past chair, National Patient Safety Foundation.  Journal for Healthcare Quality.  31(5):4-7, Sept./Oct. 2009.

Elgart, L., Gaffney, A.  Advancing patient safety through process improvements.  Journal for Healthcare Quality.  31(5):8-13, Sept./Oct. 2009.

Shea-Lewis, A.  Teamwork: crew resource management in a community hospital.  Journal for Healthcare Quality.  31(5):14-18, Sept./Oct. 2009.

Beckett, C.D., and Kipnis, G.  Collaborative communication: integrating SBAR to improve quality/patient safety outcomes.  Journal for Healthcare Quality.  31(5):19-28, Sept./Oct. 2009.

Weinschreider, J., Dadiz, R.  Back to basics: creating a simulation program for patient safety.  Journal for Healthcare Quality.  31(5):29-37, Sept./Oct. 2009.

Daniel, L.T., and Simpson, E.K.  Integrating team training strategies into obstetrical emergency simulation training. Journal for Healthcare Quality.  31(5):38-42, Sept./Oct. 2009.

Cooper, M.R., and others.  The unintended consequences of being friendly: a case study.  Journal for Healthcare Quality.  31(5):43-47, Sept./Oct. 2009.

Graham, J.M. and others.  Virtual patient safety rounds: one hospital system’s approach to sharing knowledge.  Journal for Healthcare Quality.  31(5):48-52, Sept./Oct. 2009.

Silvaugh, B. R., and Leider, H. L. Physician leadership is key to creating a safer, more reliable health care system. Physician Executive. 35(5):12-16, Sept./Oct. 2009.

Wallask, S. Time for hospitals to issue holiday decorations. Healthleaders  Media, Sept. 30, 2009.

Masterson, L. Many EDs not caring for patients fast enough. Healthleaders Media, Sept. 30, 2009.

Korc, B., and Landers, S.  Delirium in hospitalized patients may be preventableAmerican Medical News 52(21):14, 19, Sept. 28, 2009.

Shahar, A., and others.  Misleading one detail: a preventable mode of diagnostic error?  Journal of Evaluation in Clinical Practice. 15(5):804-806, Sept. 24, 2009.

West, C., and others. Association of resident fatigue and distress with perceived medical errors.  JAMA. 302(12):1294-1300, Sept. 23, 2009.

Nicastro, D.  HIPAA's harm threshold is a huge weakness. HealthLeaders Media. Sept. 21, 2009.

Health Care–Associated Infections [web site].  Rockville, MD:  Agency for Healthcare Research and Quality, accessed Sept. 2, 2009.

Communication.  Plymouth Meeting, PA :  ECRI Institute. Sept. 2009

Gamble, K. H. Cutting the cord. Healthcare Informatics.:30-33, Sept. 2009.

Hagland, M. For all the right reasons. Healthcare Informatics.:41-44, Sept. 2009.

Marx, K. Smoothing the path. Healthcare Informatics.:50-51, Sept. 2009.

Patient Safety Indicators: Technical Report.  Trenton, NJ:  New Jersey Department of Health and Senior Services.  Sept. 2009.

Baum, K., and Reifsteck, S. W. Getting physicians involved n patient safety: a team approach. MGMA Connexion. 9(8):47-50, Sept. 2009.

No goal too small. Hospitals & Health Networks. 83(9):34, Sept. 2009.

Tjia, J. and others. Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. Journal of Patient Safety. 5(3):145-152, Sept. 2009.

Sorensen, A. V., and Bernard, S. L. Strategies for safe medication use n ambulatory care settings in the United States. Journal of Patient Safety. 5(3):160-167, Sept. 2009.

Lemer, C., and others. The role of advice in medication administration errors in the pediatric ambulatory setting. Journal of Patient Safety. 5(3):168-175, Sept. 2009.

Anderson, B., Stumpf, P. G., and Schulkin, J. Medical error reporting, patient safety, and the physician. Journal of Patient Safety. 5(3):176-179, Sept. 2009.

Saxton, R., Hines, T., and Enriquez, M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. Journal of Patient Safety. 5(3):180-183, Sept. 2009.

Gross, A. C., and others. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. Journal of Patient Safety. 5(3):184-187, Sept. 2009.

Blegen, M. A., and others. AHRQ’s Hospital Survey on Patient Safety Culture: psychometric analyses. Journal of Patient Safety. 5(3):139-144, Sept. 2009.

Joint Commission. 2010 National Patient Safety Goals. Oakbrook Terrace, IL: Joint Commission, Sept. 2009. 

Farley, D., and others.  Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System.  Santa Monica, CA: RAND Corporation, Sept. 2009.

Simmons, J.  Dial ‘H’ for help.  HealthLeaders.  12(9):60-62, Sept. 2009.

Bush, H.  Beyond a safety breakthrough: after great success in Michigan, CLABSI reduction program expands.  Materials Management in Health Care.  18(9):13-15, Sept. 2009.

Aston, G.  Cohesive effort cuts infections: aligning programs, establishing metrics buoy Novant HealthMaterials Management in Health Care.  18(9):26-28, Sept. 2009.

Garrett, J., Wheeler, H., and Goetz, K.  Implementing an ‘always practice’ to redefine skin care management.  JONA. The Journal of Nursing Administration.  39(9):382-387, Sept. 2009.

Staggers, N., and Jennings, B.M.  The content and context of change of shift report on medical and surgical units.  JONA. The Journal of Nursing Administration.  39(9):393-398, Sept. 2009.

No goal too small. Hospitals & Health Networks. 83(9):34, Sept. 2009.

Tjia, J. and others. Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety. Journal of Patient Safety. 5(3):145-152, Sept. 2009.

Sorensen, A. V., and Bernard, S. L. Strategies for safe medication use n ambulatory care settings in the United States. Journal of Patient Safety. 5(3):160-167, Sept. 2009.

Lemer, C., and others. The role of advice in medication administration errors in the pediatric ambulatory setting. Journal of Patient Safety. 5(3):168-175, Sept. 2009.

Anderson, B., Stumpf, P. G., and Schulkin, J. Medical error reporting, patient safety, and the physician. Journal of Patient Safety. 5(3):176-179, Sept. 2009.

Saxton, R., Hines, T., and Enriquez, M. The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature. Journal of Patient Safety. 5(3):180-183, Sept. 2009.

Gross, A. C., and others. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. Journal of Patient Safety. 5(3):184-187, Sept. 2009.

Blegen, M. A., and others. AHRQ’s Hospital Survey on Patient Safety Culture: psychometric analyses. Journal of Patient Safety. 5(3):139-144, Sept. 2009.

Gamble, K. H. Cutting the cord. Healthcare Informatics.:30-33, Sept. 2009.

Fall prevention in ambulatory surgical centers.  Joint Commission on Patient Safety.  9(9):6-7(2), Sept.2009.

Patterson P. RI [Rhode Island] standardizes safe-site protocol. OR Manager. 25(9): 9-10, Sept. 2009.

Patterson P. In survey, about half of ORs are using the WHO checklist. OR Manager. 25(9): 1, 6-8, Sept. 2009.

Hagland, M. For all the right reasons. Healthcare Informatics.:41-44, Sept. 2009.

Marx, K. Smoothing the path. Healthcare Informatics.:50-51, Sept. 2009.

Baum, K., and Reifsteck, S. W. Getting physicians involved n patient safety: a team approach. MGMA Connexion. 9(8):47-50, Sept. 2009.

Premier/IHI algorithms automate process for identifying patient harm.  Healthcare Benchmarks and Quality Improvement.  16(9):97-99, Sept. 2009.

Wood, K., and others.  Rapid Response Systems in Adult Academic Medical Centers.  Joint Commission Journal on Quality and Patient Safety.  35(9):475-482, 8, Sept. 2009.

Fuller, R., and others. Estimating the costs of potentially preventable hospital acquired complications. Health Care Financing Review. 30(4):17-32, Summer 2009.

Averill, R., and others. Redesigning the Medicare Inpatient PPS to reduce payments to hospitals with high readmission rates. Health Care Financing Review. 30(4):1-1, Summer 2009.

Kearns, S. Hospital Uses EMRs to avoid drug errors. HealthLeaders Media, Aug. 31, 2009.

Joint Commission. Leadership committed to safety. Sentinel Event Alert, issue 43, Aug. 27, 2009.

Clark, C.  Hospitals in nine states jeopardize patient safety with lack of H1N1 readinessHealthLeaders Media.  Aug. 27, 2009.

Pronovost PJ, Faden RR. Setting priorities for patient safety: ethics, accountability, and public engagement.
JAMA (Journal of American Medical Association). 302(8):890-891, Aug. 26, 2009.

Simmons, J.  18 Medication management measures released by National Quality Forum . Healthleaders Media. Aug 20, 2009.

Indiana State Department of Health.  Indiana Medical Error Reporting System: Final Report for 2008.  Indianapolis, IN: ISDH, Aug. 20, 2009.

Clark, C.  Many hospitalized patients leave facilities against medical adviceHealthLeaders Media.  Aug. 20, 2009.

Fry, D., and Neverland, P. Denying payments for never events is based on the illusion that these events are always avoidable. A better system is to use health care "warranties”. Hospitals & Health Networks Online, Aug. 17, 2009.

Dead by mistake [series]. Hearst Newspapers and San Francisco Chronicle, accessed Aug. 14, 2009.  

Wilson L. A systematic approach. 100 Top Hospitals – Health systems quality/efficiency study. Modern Healthcare.  39(2):26-28, Aug. 10. 2009.

Gosselar, G., and others.  Back to Basics.  Washington, DC: Public Citizen; Aug. 6, 2009.

Prescription Errors with Use of Computerized Physician Order Entry Pose Safety RiskJournal of Clinical Outcomes Management, Aug. 6, 2009.

Sweeney, E.  Don’t get tagged for infection control deficiencies in the MRIHealthleaders Media. Aug. 4, 2009.

Thobaben, M. How to avoid medication errors: six tips for clients/caregivers.  Home Health Care Management Practice. 21(5):363-365, Aug. 1, 2009.

Fox, E. and others.  ASHP guidelines on managing drug product shortages in hospitals and health systems.  American Journal of Health-System Pharmacy.  66(15):1399-1406, Aug. 1, 2009.

Five-year report card for the "Universal Protocol" to prevent wrong site surgery. Premier Safety Institute News, Aug. 2009.

90-day guarantee: warranties as a tool for improved patient outcomes. OR Manager. 25(8):1, 19-20, Aug. 2009.

Surgical Care Improvement Project: four years later, what’s the status? OR Manager. 25(8):1, 7-18, Aug. 2009.

“Never events”: sorting out confusion. OR Manager. 25(8):21-22, Aug. 2009.

Aston, G.  Fresh approaches to stem MRSA tide.  Materials Management in Health Care.  18(8):22-25, Aug. 2009.

Eash, B.A.  Changing attitudes strengthen culture of prevention.  Materials Management in Health Care.  18(8):32, Aug. 2009.

Hayes, W.S.  Use evidence to put prevention in context.  Materials Management in Health Care.  18(8):18-21, Aug. 2009.

Huber, L.  Net widens on scope processing error incidents.  Materials Management in Health Care.  18(8):30, Aug. 2009.

Hospitals make progress on managing meds.  Materials Management in Health Care.  18(8):4, Aug. 2009.

Prevent the spread of MRSA.  Materials Management in Health Care.  18(8):26-28, Aug. 2009.

Santamore, B., and Bush, H.  Pursuing excellence: AHA initiative demonstrates value of teamwork in improving safety.  Materials Management in Health Care.  18(8):14-17, Aug. 2009.

Wallace, L., and others.  Improving patient safety incident reporting systems by focusing upon feedback – lessons from English and Welsh trusts.  Health Services Management Research.  22(3):129-135, Aug. 2009.

Stranges, E., and others.  Hospitalizations in Which Patients Leave the Hospital Against Medical Advice (AMA), 2007. Statistical Brief #78.  Rockville, MD:  Agency for Healthcare Research and Quality, Aug. 2009.

Is patient safety recession-proof?  Joint Commission Perspectives on Patient Safety. 9(8):1, 3-4, 11, Aug. 2009.

The state of safety. An interview with Robert M. Wachter, M. D.  Joint Commission Perspectives on Patient Safety. 9(8):10-11, Aug. 2009.

TJC issues report on tracking HCW hand hygiene.  Healthcare Benchmarks and Quality Improvement.  16(8):88-90, Aug. 2009.

Compliance with verbal orders standards poor; and, Verbal orders placed in new chapter.  Healthcare Benchmarks and Quality Improvement.  16(8):91-92, Aug. 2009.

90-day guarantee: warranties as a tool for improved patient outcomes. OR Manager. 25(8):1, 19-20, Aug. 2009.

Surgical Care Improvement Project: four years later, what’s the status? OR Manager. 25(8):1, 7-18, Aug. 2009.

“Never events”: sorting out confusion. OR Manager. 25(8):21-22, Aug. 2009.

Audits help manager track compliance.  Healthcare Benchmarks and Quality Improvement.  16(8):91, Aug. 2009.

Safely storing meds is problem for many.  Healthcare Benchmarks and Quality Improvement.  16(8):92-93, Aug. 2009.

Items to check off for LSC compliance.  Healthcare Benchmarks and Quality Improvement.  16(8):93-94, Aug. 2009.

Put a stop to IV med errors with 4 practices.  Healthcare Benchmarks and Quality Improvement.  16(8):94, Aug. 2009.

Transparent purchasing could improve quality.  Healthcare Benchmarks and Quality Improvement.  16(8):94-95, Aug. 2009.

Sebelius challenges hospitals to fight HAIs.  Healthcare Benchmarks and Quality Improvement.  16(8):95-96, Aug. 2009.

Bates, D., and others.  Medication safety technologies: What is and is not workingMedication Safety Technologies.  July/Aug. 2009.

Clancy, C.  Patient safety councils: a new tool for patient safetyMedication Safety Technologies.  July/Aug. 2009.

Rashidee, A., and others.  High-alert medications: Error prevalence and severityMedication Safety Technologies.  July/Aug. 2009.

Tregunno, D., and others.  On the ball: leadership for patient safety and learning in critical care.  JONA: Journal of Nursing Administration.  39(7/8):334-339, July/Aug. 2009.

Virkstis, K., and others.  Safeguarding quality: building the business case to prevent nursing-sensitive hospital-acquired conditions.  JONA: Journal of Nursing Administration.  39(7/8):350-355, July/Aug. 2009.

Jones, D. S., and Jafe, R. S. Patient safety organizations: champions for quality.  Journal of Health Care Compliance. 11(4):43-48, July/Aug. 2009.

Comak, H. Health reform bill features healthcare associated infections database.Healthleaders Media. July 21, 2009.

Kearns, S. Process maps improves the patient ID processes. Healthleaders Media. July 9, 2009.

Were, M., and others.  Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providersJournal of General Internal Medicine.  July 6, 2009.  (Online).

Phillion, M.  Eliminating workarounds prevents medication errorsHealthLeaders Media.  July 1, 2009.

Patient Safety Primers [web site]. Agency for Healthcare Research and Quality, accessed July 1, 2009.

Helmons, P. J., Wargel, L. N., and Daniels, C. E. Effect of bar-code-assisted medication administration on medication administration errors and accuracy in multiple patient care areas.  American Journal of Health-System Pharmacy. 66(13): 1202-1210, July 1, 2009.

O’Reilly, K. B. Can patient safety be recession-proof?   American Medical News. 52(18):9-10, July 2009.

Gulwadi, G.B, and Keller, A.B.  Falls in healthcare settings.  Healthcare Design.  9(7):28, 30, 32, 34, July 2009.

Patterson, P. Educating patients on SSI prevention. OR Manager.25(7):21-22, July 2009.

Williamson, J. E. From simple to high-tech, solutions help slash patient safety risks. Healthcare Purchasing News.33(7):18-23, July 2009.

Kern, L. M., and others. Measuring the effects of health information technology on quality of care: a novel set of proposed metrics for electronic quality reporting. Joint Commission Journal on Quality and Patient Safety. 35(7):359-369, July 2009.

Sarkar, U., and others. Refocusing the lens: patient safety in ambulatory chronic disease care. Joint Commission Journal on Quality and Patient Safety. 35(7): 377-383, July 2009.

Henderson, K. E., and others. Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator.  Joint Commission Journal on Quality and Patient Safety. 35(7):370-376, July 2009.

McCormick, T., and Hern, W. Aligning risk management with patient safety. Healthcare Financial Management. 63(7):68-72, July 2009.

Sandrick, S. Leading a culture of safety. Trustee. 62(7):6-10, July 2009.

Williamson, J. E. From simple to high-tech, solutions help slash patient safety risks. Healthcare Purchasing News.  33(7):18-23, July 2009.

Casalino, L., and others. Frequency of failure to inform patients of clinically significant outpatient test results. Archives of Internal Medicine.  169(12):1123-1129,June 22, 2009

DeYoung, J., Vanderkiooi, M., and Barletta J. Effect of bar-code-assisted medical administration on medication error rates in an adult medical intensive care unit. American Journal of Health-System Pharmacy. 66(12):1110-1115, June 15, 2009.

Hanuscak, T., and others.  Evaluation of causes and frequency of medication errors during information technology downtime. American Journal of Health-System Pharmacy. 66(12):1119-1124, June 15, 2009.

Mims, E., and others. Quality-monitory program for bar-code-assisted medication administration. American Journal of Health-System Pharmacy. 66(12):1125-1131, June 15, 2009.

Comak, H. Senior leaders learn during patient safety rounds. HealthLeaders Media. June 11, 2009.

Vaughan, C. Technology offers real-time monitoring of hand washingHealthleaders Media. June 9, 2009.

Youngstrom, N. Some hospital acquired conditions are seen as unpredictable, but urgency grows for patient safety initiativesReport on Medicare Compliance, June 9, 2009.

Howell, S., and others. Using Routine Inpatient Data to Identify Patients at Risk of Hospital Readmission . London, United Kingdom: BMC Health Services Research. June 9, 2009.

Comak, H. Most hospitals working toward creating strong cultures of safetyHealthleaders Media. June 8, 2009.

Beyond the Count: Preventing the Retention of Foreign ObjectsPennsylvania Patient Safety Advisory.  6(2):39-45, June 2009.

Singh, R., and others. A patient safety objective structured clinical examination. Journal of Patient Safety. 5(2):55-60, June 2009.

Study shows disappointing results in many safety indicators. Healthcare Benchmarks and Quality Improvement. 16(6):61-65, June 2009.

Guide to the Elimination of Catheter Associated Urinary Tract Infections (CAUTIs).  Washington, DC:  APIC.  June, 2009.

With 0% surgical infection rate, improvement needed. Healthcare Benchmarks and Quality Improvement. 16(6): 65-66, June 2009.

Is MRSA on the run? CEOs getting on board. Healthcare Benchmarks and Quality Improvement. 16(6): 67-70, June 2009.

MRSA drops in ICUs, but BSI battle awaits in wards. Healthcare Benchmarks and Quality Improvement. 16(6):70-72, June 2009.

Break down these barriers to medication safety. Healthcare Benchmarks and Quality Improvement. 16(6):66-67, June 2009.

2008 National Progress Report on e-Prescribing.  Alexandria, VA: Surescripts, June 2009. [State-level reports].

Shulkin, D. Assessing hospital safety on nights and weekends: the SWAN Tool. Journal of Patient Safety. 5(2):75-78, June 2009.

Feleke, R., and others. Color coded medication safety system reduces community pediatric emergency nursing medication errors. Journal of Patient Safety. 5(2):79-85, June 2009.

2009 APIC Economic Survey The Economic Downturn and Infection Prevention Results of an Online Poll of Infection Preventionists . Washington: Association for Professionals in Infection Control & Epidemiology, June 2009.

Eagle, A. Standing tall environmental improvements for reducing patient fallHealth Facilities Management, June, 2009.

Skapik, J., and others. Pediatric safety incidents from an intensive care reporting system. Journal of Patient Safety. 5(2):95-101, June 2009.

Bepko, R., Moore, J., and Coleman, J.  Implemantation of a pharamacy automation system (robotics) to ensure medication safety at Norwalk Hospital.  Quality Management in Health Care.  18(2):103-114, Apr./June 2009.

Bisognano, M., and Boutwell, A.  Improving transitions to reduce readmissions.  Frontiers of Health Services Management. 25(3): 3-10, Spring 2009.

Chugh, A., and others.  Better transitions: improving comprehension of discharge instructions. Frontiers of Health Services Management. 25(3): 11-32, Spring 2009.

Paine, L., and Millman, A.  Sealing the cracks, not falling through using handoffs to improve patient care.  Frontiers of Health Services Management. 25(3): 33-38, Spring 2009.

Lattimer, C.  Better coordination of care reduces readmissions. Frontiers of Health Services Management. 25(3): 43-46, Spring 2009.

Crowley, J., and Deen, J.  Leadership practices to advance patient safetyPatient Safety in Quality Healthcare. 6:18-22, May/June 2009.

Buetow, S., and others. Patient error a preliminary taxonomy. Annuals of FamilyMedicine. 7(3):223-231, May/June. 2009.

Lubell, J.  Reduce More Errors: Experts.  Modern Healthcare.  39(21):16, May 25, 2009.

O’Reilly, K.B.  Yale Obstetrics Safety Plan Cuts Adverse Events by 40%.  American Medical News.  52(14):11, 16, May 25, 2009.

Volpp, K., and others.  Did duty hour reform lead to better outcomes among the highest risk patients?  Journal of General Internal Medicine.  May 20, 2009.  (Online).

Comak, H. Facility identifies 4 ways to lower CLABSI rates. HealthLeaders Media. May 4, 2009.

Burnett, K.M., and others.  Effects of an integrated medicines management program on medication appropriateness in hospitalized patients.  American Journal of Health-System Pharmacy.  66(9):854-859, May 1, 2009.

Santell, J.P., and others.  Medication errors resulting from computer entry by nonprescribers.  American Journal of Health-System Pharmacy.  66(9):843-853, May 1, 2009.

Rollins G. 2009 infection prevention & hospital cleaning survey. How clean is clea? New technologies, monitoring practices gain traction. Materials Management in Health Care. 18(5):18-24, May 2009.

Oriola S. Infection control hotline: understanding VRE is key to preventionMaterials Management in Health Care. 18(5):34-36, May 2009.

To err is human-to delay is deadly ten years later, a million lives lost, billions of dollars wasted . Austin, TX: Consumers Union. May 2009.

Lesselroth, B., and others. Using consumer-based kiosk technology to improve and standardize medication reconciliation in a specialty care setting. Joint Commission Journal on Quality and Patient Safety. 35(5):264-270, May 2009.

Stock, R., Scott, J., and Gurtel, S. Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group. Joint Commission Journal on Quality and Patient Safety. 35(5):271-277, May 2009.

Gardner, B., and Graner, K. Pharmacists’ medication reconsiliation-related clinical interventions in a children’s hospital. Joint Commission Journal on Quality and Patient Safety. 35(5):278-282, May 2009.

Dirty scope incidents put processing practices under microscope.  Healthcare Purchasing News.  33(5):22, May 2009.

Truscott, W.  Importance of oral care in the prevention of VAP.  Healthcare Purchasing News.  33(5):36-37, May 2009.

Checklist helps improve OR safety in just minutes. Healthcare Risk Management. 31(5):58-59, May 2009.

Troxel, D.  Do health system errors cause medical malpractice claims?  Bulletin of the American College of Surgeons.  94(5):30-31, May 2009.

U.S. providers challenged to reduce cost of HAIs.  Healthcare Financial Management.  63(5):94, May 2009.

Montana RHIO seeks to improve patient safety and efficiency.  Healthcare Benchmarks and Quality Improvement.  16(5):49-51, May 2009.

Biehl, M. First, do less harm: the Patient Safety and Quality Improvement Act of 2005 – final rule. Health Lawyers News. 13(5):20-24, May 2009.

Safe Patient Project. To err is human -- to delay is deadly.  Yonkers, NY: Consumers Union, May 2009.

Pope, D., Morrison, G., and Hansen, T. MRSA reduction: myths and facts. Nursing Management. 40(5):24-29, May 2009.

Association between hospital-reported Leapfrog safe practices scores and inpatient...  Journal of the American Medical Association (JAMA).   301(16):1341-1348, Apr. 22/29, 2009.

Swartz, T.  Evidence-based hospital design improves patient safetyHealthLeaders Media.  Apr. 28, 2009.

Lubell, J.  Red flags raised: hospitals wary of interest in readmission rates.  Modern Healthcare.  39(16):8-9, Apr. 20, 2009.

Leapfrog Hospital Survey Results 2008.  Washington, DC: Leapfrog Group, Apr. 15, 2009.  [Hospital Detail Report]. 

O’Reilly, K.B.  Initiative to cut catheter infections expands.  American Medical News.  52(11):10, 13, Apr. 13, 2009.

Success Story in American Health Care Eliminating Infections Saving Lives in Michigan.  Washington: Healthreform.Gov. Apr.1, 2009.

Seton Family of Hospitals and BD Use GS1 Standards and Processes to Reduce EDI Errors in Pursuit of “ Perfect Orders”. Lawrenceville, NJ: GS1 US Inc,Apr. 2009.

Vilamovska, A., and Conklin, A.  Improving patient safety addressing patient harm arising from medical errorsPolicy Insight. 3 (2) 1-4, Apr. 2009.

AHAQuality Center.  In Pursuit of Excellence: a Guide to Superior Performance Improvement. Chicago: American Hospital Association, Apr. 2009.

Golder, S., and Loke, Y. K. Search strategies to identify information on adverse effects: a systematic review. Journal of the Medical Library Association.  97(2):84-92, Apr. 2009.

Preventing technology-related health care errors.  Bulletin.  94(4):51-52, Apr. 2009.

Fantus, R.  How complicated is it?  Bulletin.  94(4):55-56, Apr. 2009.

Ollapally, V.  The NCDs for “never events.” Bulletin.  94(4):6-7, Apr. 2009.

Lederer, J.W., Best, D., and Hendrix, V., A comprehensive hand hygiene approach to reducing MRSA health care-associated infections. Journal on Quality and Patient Safety.  35(4):180-185, Apr 2009.

Ryckman, F.C., and others.  Reducing surgical site infections at a Pediatric Academic Medical Center.  Journal on Quality and Patient Safety. 35(4):192-198, Apr 2009.

Bader, M.K., and others.  Rescue me: saving the vulnerable non-ICU patient population.  Journal on Quality and Patient Safety. 35(4):199-205, Apr. 2009.

Brown, R.H., and others.  The final steps in converting a health care organization to a latex-safe environment. Journal on Quality and Patient Safety. 35(4):224-228, Apr. 2009.

Spell it out: ensuring compliance with do-not-use abbreviation policies. Joint Commission Perspectives on Patient Safety. 9(4):1-4, Apr.2009.

Preventing never events: pressure ulcers.  Joint Commission Perspectives on Patient Safety. 9(4):5-7, Apr.2009.

Assessing patients’ potential suicide risk.  Joint Commission Perspectives on Patient Safety. 9(4):8-9, Apr.2009.

Clarification: the effect of disruptive behavior on a culture of safety. Joint Commission Perspectives. 29(4):10, Apr. 2009.

Teleki, S.S., and others.  Training a patient safety work force: the patient safety improvement corps.  Health Services Research. 44(2): 701-716, Apr. 2009.

Greenberg, M.D., and others.  Safety outcomes in the United States: trends and challenges in measurement. Health Services Research. 44(2):739-755, Apr. 2009.

Aston, G.  Pump up your data: tracking smart pump trends can boost safety, outcomes.  Materials Management in Health Care.  18(4):14-18, Apr. 2009.

Bahrt, G.  Current methods for combating VAP.  Nursing Management.  40(4):49-52, Apr. 2009.

Kemper, C., and Boyle, D.K.  Leading your organization to high reliability.  Nursing Management.  40(4):14-18, Apr. 2009.

Kutash, M., and Short, M.  The lift team’s importance to a successful safe patient handling program.  JONA. The Journal of Nursing Administration.  39(4):170-175, Apr. 2009.

MacKrell, T.  Foregoing the great paper chase: electronic tracking of infections promotes accuracy, safety.  Materials Management in Health Care.  18(4):26-28, Apr. 2009.

Make room for the basics: environmental cleanliness gains new attention in HAI strategies.  Materials Management in Health Care.  18(4):9-12, Apr. 2009.

Ortiz, J., and Amatucci, C.  A case of mistaken identity: staff input on patient ID errors.  Nursing Management.  40(4):37-41, Apr. 2009.

Preventing technology-related health care errors.  Bulletin.  94(4):51-52, Apr. 2009.

Fantus, R.  How complicated is it?  Bulletin.  94(4):55-56, Apr. 2009.

Ollapally, V.  The NCDs for “never events.” Bulletin.  94(4):6-7, Apr. 2009.

Lederer, J.W., Best, D., and Hendrix, V., A comprehensive hand hygiene approach to reducing MRSA health care-associated infections. Journal on Quality and Patient Safety.  35(4):180-185, Apr 2009

Ryckman, F.C., and others.  Reducing surgical site infections at a Pediatric Academic Medical Center.  Journal on Quality and Patient Safety. 35(4):192-198, Apr 2009.

Bader, M.K., and others.  Rescue me: saving the vulnerable non-ICU patient population.  Journal on Quality and Patient Safety. 35(4):199-205, Apr. 2009.

Brown, R.H., and others.  The final steps in converting a health care organization to a latex-safe environment. Journal on Quality and Patient Safety. 35(4):224-228, Apr. 2009.

Spell it out: ensuring compliance with do-not-use abbreviation policies. Joint Commission Perspectives on Patient Safety. 9(4):1-4, Apr.2009.

Preventing never events: pressure ulcers.  Joint Commission Perspectives on Patient Safety. 9(4):5-7, Apr.2009.

Assessing patients’ potential suicide risk.  Joint Commission Perspectives on Patient Safety. 9(4):8-9, Apr.2009.

Clarification: the effect of disruptive behavior on a culture of safety. Joint Commission Perspectives. 29(4):10, Apr. 2009.

Teleki, S.S., and others.  Training a patient safety work force: the patient safety improvement corps.  Health Services Research. 44(2): 701-716, Apr. 2009.

Greenberg, M.D., and others.  Safety outcomes in the United States: trends and challenges in measurement. Health Services Research. 44(2):739-755, Apr.2009.

Viola, A., Kallem, C., and Bronnert, J.  A next act for patient safety.  Journal of AHIMA.  80(4):30-35, Apr. 2009.

Getting surgical teams on board for OR checklists and briefings.  OR Manager.  25(4):1, 9-10, 13, Apr. 2009.

Singer, S., and others.  Relationship of safety climate and safety performance in hospitals.  Health Services Research.  44(2):Part I:399-421, Apr. 2009.

Santamour, B.  Aiming for perfectionHospitals and Health Networks.  83(4):18-21, Apr. 2009.

Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.  Rockville, MD:  Agency for Healthcare Research and Quality, Apr. 2009.

Stegman, M.  Adverse events in hospitals and the hospital-acquired condition (HAC) initiative.  Journal of Health Care Compliance.  11(2):59-60, Mar./Apr. 2009.

Kadzielski, M., and Mitchel, L.  An analysis of the new federal patient safety law and final rule.  Journal of Health Care Compliance.  11(2):5-16, Mar./Apr. 2009.

Friedman, M., Schueth, A., and Bell, D.  Interoperable electronic prescribing in the United States:  a progress report.  Health Affairs.  28(2):393-403, Mar./Apr. 2009.

Aarts, J., and Koppel, R.  Implementation of computerized physician order entry in seven countries.  Health Affairs.  28(2):404-414, Mar./Apr. 2009.

Welcome to the PSO Privacy Protection Center.  PSO Privacy Protection Center, Mar. 17, 2009.

Benkirane, R., and others.   Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study.  Journal of Patient Safety. 5(1):16-22, Mar. 2009.

Holden, L.M., Watts, D.D., and Walker, P.H.,  Patient safety climate in primary care: age matters.  Journal of Patient Safety. 5(1):23-28, Mar. 2009.

Flanders, S.A., and others.  Hospitalists as emerging leaders in patient safety: lessons learned and future directions. Journal of Patient Safety. 5(1):3-8, Mar. 2009.

Central line associated bloodstream infections.  The Joint Commission Perspectives on Patient Safety.  9(3): 1,3-4,11, Mar. 2009.

Douglas, R.  The Direct Medical Costs of Healthcare Associated Infections in U.S. Hospitals and the Benefits of Prevention.  Atlanta, GA: Centers for Disease Control and Prevention.  Mar. 2009.

Strategies for eliminating catheter related urinary tract infection. The Joint Commission Perspectives on Patient Safety.  9(3): 5-7, 11, Mar. 2009.

Vassilev, Z., and others.  Evaluation of adverse drug reactions reported to a Poison control center between 2000 and 2007. American Journal of Health System Pharmacy. 66(5): 481-486. Mar. 2009.

Benkirane, R., and others.   Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study.  Journal of Patient Safety. 5(1):16-22, Mar. 2009.

Holden, L.M., Watts, D.D., and Walker, P.H.,  Patient safety climate in primary care: age matters.  Journal of Patient Safety. 5(1):23-28, Mar. 2009.

Flanders, S.A., and others.  Hospitalists as emerging leaders in patient safety: lessons learned and future directions. Journal of Patient Safety. 5(1):3-8, Mar. 2009.

Central line associated bloodstream infections.  Joint Commission Perspectives on Patient Safety.  9(3): 1,3-4,11, Mar. 2009.

Strategies for eliminating catheter related urinary tract infection. Joint Commission Perspectives on Patient Safety.  9(3): 5-7, 11, Mar. 2009.

Vassilev, Z., and others.  Evaluation of adverse drug reactions reported to a Poison control center between 2000 and 2007. American Journal of Health System Pharmacy. 66(5): 481-486. Mar. 2009.

Cima, R., and others.  A multidisciplinary team approach to retained foreign objects.  Joint Commission on Quality and Patient Safety.  35(3):123-132, Mar. 2009.

Patterson, P.  Who surgical safety checklist linked to fewer deaths, complications.  OR Manager.  25(3):1, 7-8, Mar. 2009.

Medical Office Survey on Patient Safety Culture.  Rockville, MD:  Agency for Healthcare Research and Quality, Mar. 2009.

Hughes, L.C., Chang, Y., and Mark B.A.   Quality and strength of patient safety climate on medical-surgical units. Health Care Management Review. 34(1): 19-28, Jan./Mar. 2009.

Wynn, J., Engelke, M., and Swanson, M.  The front line of patient safety:  staff nurses and rapid response team calls.  Quality Management in Health Care.  18(1):40-47, Jan./Mar. 2009.

Karlsen, K., Hendrix, T., and O'Malley, M.  Medical error reporting in America:  a changing landscape.  Quality Management in Health Care.  18(1):59-70, Jan./Mar. 2009.

Yee, P., and others.  Implementation of patient safety rounds in a children's hospital.  Nursing Administration Quarterly.  33(1):48-53, Jan./Mar. 2009.

Hughes, L.C., Chang, Y., and Mark B.A.   Quality and strength of patient safety climate on medical-surgical units. Health Care Management Review. 34(1): 19-28, Jan./Mar. 2009.

Cahill, M.  Pediatric medication safety:  the power of the team.  Nursing Administration Quarterly.  33(1):38-47, Jan./Mar. 2009.

Serb, C.  Seeing the light with CPOEH & HN Online.  Feb. 17, 2009.

Habel, M.  Promoting a culture of safety to prevent medical errors.  Nursing Spectrum.  22(3):18-23, Feb. 9, 2009.

Senders, J.  Profiles in Improvement: John Senders of the University of Toronto.  Cambridge, MA:  Institute for Healthcare Improvement, Feb. 4, 2009.

National study probes ties between ‘best practices’ surgical infection. OR Manager.  25(2):1, 7-8, Feb. 2009.

Curran, C.,  Managing ORs in tough economic times. OR Manager.  25(2):5, Feb. 2009.

Ginsburg, L., and others. Advancing measurement of patient safety culture.  Health Services Research.  44(1): 205-224, Feb.2009.

Romano, P., and others.  Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program Data.  Health Services Research.  44(1):182-204, Feb.2009.

Preventing never events: stopping air embolisms during surgery.  Joint Commission Perspectives on Patient Safety. 9(2) 1, 3, Feb. 2009.

Wesolowski, C., Preventing medication errors in hospitalized children.  American Journal of Health-System Pharmacy. 66(3): 287-290, Feb. 2009.

National study probes ties between ‘best practices’ surgical infection. OR Manager. 25(2):1, 7-8, Feb. 2009.

Curran, C.,  Managing ORs in tough economic times. OR Manager.  25(2):5, Feb. 2009.

Ginsburg, L., and others. Advancing measurement of patient safety culture.  Health Services Research.  44(1): 205-224, Feb.2009.

Romano, P., and others.  Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program Data.  Health Services Research.  44(1):182-204, Feb.2009.

Preventing never events: stopping air embolisms during surgery.  Joint Commission Perspectives on Patient Safety. 9(2) 1, 3, Feb. 2009.

Wesolowski, C., Preventing medication errors in hospitalized children.  American Journal of Health-System Pharmacy. 66(3): 287-290, Feb. 2009.

Park-Lee, E., and Caffrey, C.  Pressure Ulcers Among Nursing Home Residents: United States, 2004.  Washington:  Department of Health and Human Services, Feb. 2009.

Herzer, K., and others.  A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.  Joint Commission Journal on Quality and Patient Safety.  35(2):72-81, Feb. 2009.

Brokel, J., and Harrison, M.  Redesigning care process using an electronic health record:  a system's experience.  Joint Commission Journal on Quality and Patient Safety.  35(2):82-92, Feb. 2009.

DeJohn P.  Materials, infection control unite to beat infectious diseases.  Materials Management in Health Care.  18(2):10-14, Feb. 2009.

New sentinel event alert gives warning:  IT implementation has inherent safety risks.  Suppl. to ED Management.  21(2):1-4, Feb. 2009.

Rauch, K., Balascio, J., and Gilbert, P.  Excellence in action:  developing and implementing a fall prevention program.  Journal for Healthcare Quality.  31(1);36-42, Jan./Feb. 2009.

Hines, P.A., and Yu, K.M.  The changing reimbursement landscape: nurses' role in quality and operational excellence.  Nursing Economics.  27(1):7-13, Jan./Feb. 2009.

Haynes, A., and others.  A surgical checklist to reduce morbidity and mortality in a global populationNew England Journal of Medicine.  360(5):491-499, Jan. 29, 2009.

Combes, J.,  New program targets infections in ICUs across the country.  Materials Management in Health Care.  18(1):9-11, Jan. 2009.

Health Care Protocol: Perioperative Protocol.  Bloomington, MN:  Institute for Clinical Systems Improvement.  Jan. 2009.

Winifred, H.,  Looking past the silver lining.  Materials Management in Health Care.  18(1):20-23, Jan. 2009.

Patrick, M.,  Technology’s role in infection prevention. Materials Management in Health Care.  18(1):24-26, Jan. 2009.

Torner, N.,  Automated tools aid in infection control.  Materials Management in Health Care.  18(1):27-29, Jan. 2009.

National patient safety goals undergoing review during 2009 no new NPSGs for 2010.  The Joint Commission Perspectives. 29(1): 1,7, Jan. 2009.

Safely implementing health information and converging technologies. The Joint Commission Perspectives. 29(1): 10-13, Jan. 2009.

Crome, P., Quality improvement initiatives play an important role in today’s health care World.  Voice of Nursing Leadership.  7(1):8-9, Jan. 2009.

Sattinger, A.  Hospitalists use human factors engineering to prevent error.  The Hospitalist. 13(1): 1, 26-28, Jan. 2009.

Towne, J. Pursing excellence with pressure ulcer prevention. Voice of Nursing Leadership. 7(1):10-11, Jan. 2009.

Warye, K., and Granato, J. Target :zero hospital-acquired infections. Healthcare Financial Management. 63(1):86-91, Jan. 2009.

Case study: preventing MRSA in the Neonatal Intensive Care Unit at Beth Israel Medical Center.  Joint Commission Perspectives on Patient Safety. 9(1): 1, 3-5, Jan. 2009.

Aiello, M.  Teamwork scores hand hygiene success.  Healthcare Marketing Advisor. 10(1): 4-5, Jan. 2009.

Bielen, R.  Going under the knife.  Journal NFPA.  103(1): 40-45, Jan. 2009.

Combes, J.,  New program targets infections in ICUs across the country.  Materials Management in Health Care.  18(1):9-11, Jan. 2009.

Winifred, H.,  Looking past the silver lining.  Materials Management in Health Care.  18(1):20-23, Jan. 2009.

Patrick, M.,  Technology’s role in infection prevention. Materials Management in Health Care.  18(1):24-26, Jan. 2009.

Torner, N.,  Automated tools aid in infection control.  Materials Management in Health Care.  18(1):27-29, Jan. 2009.

National patient safety goals undergoing review during 2009 no new NPSGs for 2010.  Joint Commission Perspectives.  29(1): 1,7, Jan. 2009.

Safely implementing health information and converging technologies.  Joint Commission Perspectives. 29(1): 10-13, Jan. 2009.

Crome, P., Quality improvement initiatives play an important role in today’s health care World.  Voice of Nursing Leadership.  7(1):8-9, Jan. 2009.

Sattinger, A.  Hospitalists use human factors engineering to prevent error.  Hospitalist. 13(1): 1, 26-28, Jan. 2009.

Towne, J. Pursing excellence with pressure ulcer prevention. Voice of Nursing Leadership. 7(1):10-11, Jan. 2009.

Warye, K., and Granato, J. Target :zero hospital-acquired infections. Healthcare Financial Management. 63(1):86-91, Jan. 2009.

Case study: preventing MRSA in the Neonatal Intensive Care Unit at Beth Israel Medical Center.  Joint Commission Perspectives on Patient Safety. 9(1): 1, 3-5, Jan. 2009.

Aiello, M.  Teamwork scores hand hygiene success.  Healthcare Marketing Advisor.  10(1): 4-5, Jan. 2009.

Bielen, R.  Going under the knife.  Journal NFPA.  103(1): 40-45, Jan. 2009.

Cantrell, S.  Infection Connection.  Bundling: the KISS method for preventing HAIs.  Healthcare Purchasing News.  33(1):24-28, Jan. 2009.

Semmelmayer, M.  Lessons from the road:  education, communication help staff members in preventing HAIs.  Healthcare Purchasing News.  33(1):43, Jan. 2009.

DeJohn, P.  ASCs take steps to impove handoffs.  OR Manager.  25(1):26-27, 29, Jan. 2009.

Weir, C., and McCarthy, C.  Using implementation safety indicators for CPOE implementation.  Joint Commission Journal on Quality and Patient Safety.  35(1);21-28, Jan. 2009.

Scott-Cawiezell, J., and others.  Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.  Joint Commission Journal on Quality and Patient Safety.  35(1);29-35, Jan. 2009.

Gupta, P., and Varkey, P.  Developing a tool for accessing competency in root cause analysis.  Joint Commission Journal on Quality and Patient Safety.  35(1);36-42, Jan. 2009.

Juarez, A., and others.  Barriers to emergency departments' adherence to four medication safety-related joint commission national patient safety goals.  Joint Commission Journal on Quality and Patient Safety.  35(1);49-59, Jan. 2009.

Dall, T., and others.  The economic value of professional nursingMedical Care.  47(1):97-104, Jan. 2009.

The Seventh Annual HealthGrades Hospital Quality and Clinical Excellence Study.  HealthGrades, Jan. 2009.  [News Release Summary].

Adverse Health Events in Minnesota.  St. Paul, MN:  Minnesota Department of Health (MDH), Jan. 2009.

Adverse Health Care Events Reporting System: What Have We Learned.  St. Paul, MN:  Minnesota Department of Health (MDH), Jan. 2009.

Horwitz, L., and others.  US emergency department performance on wait time and length of visit.  Annals of Emergency Medicine, 2009.

Anderson, D., and others.  Clinical and financial outcomes due to methicillin resistant staphylococcus aureus surgical site unfection: A multi-center Matched outcomes study.  PLoS ONE.  4(12):e8305, 2009. 

Informing Practice Patient Safety and Team Training. Chicago: Health ResearchEducational Trust. 2009.

Implementation Guide: Goal 1: Reducing High Risk Pressure Ulcers.  Washington:  U.S. Department of Health and Human Services, 2009.

Stead, W., and Lin, H.  Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions.  Washington:  The National Academies Press, 2009.

Hospital Survey on Patient Safety Culture:2009 Comparative Database Report. Washington: Agency for Healthcare Research and Quality. 2009.

Safety Perspectives on American Health Care.  South Bend, IN:  Press Ganey.  2009.

2009: Annual Benchmarking Report. Malpractice Risks in Surgery.  rmfstrategies, 2009.

Turney, S., and others.  Meeting the Challenge of Patient Safety in the Ambulatory Care SettingEnglewood Cliffs, CO: Medical Group Management Association; 2009.

Straube, B., and Blum, J.  The policy on paying for treating hospital-acquired conditions: CMS officials respondHealth Affairs.   28(5):1494-1497, 2009.

Veltman, L.  Vaginal birth after cesarean checklist: an evidence-based approach to improving care during VBAC trials.  Journal of Healthcare Risk Management.  29(1):22-27, 2009.

West, J.C.  ‘Ticket to ride’: how useful is this new handoff tool?  Journal of Healthcare Risk Management.  29(1):28-33, 2009.

ISMP's List of Confused Drug Names.  Institute for Safe Medication Practices, 2009.

Birk, S. Creating a culture of safety: why CEOs hold the key to improved outcomes. World Hospitals and Health Services. 45(2):5-7, 2009.

Leotsakos, A., and others. High 5s: addressing excellence in patient safety. World Hospitals and Health Services. 45(2):19-22, 2009.

Gardam, M. A., and others. Healthcare-associated infections as patient safety indicators. Healthcare Papers. 9(3):8-24, 2009.

Jansen, I., and Murphy, J. Environmental cleaning and healthcare-associated infections. Healthcare Papers. 9(3):38-43, 2009.

Boscart, V. M., and others. Advanced technologies to curb healthcare-associated infections. Healthcare Papers. 9(3):51-55, 2009.

HHS Action Plan to Prevent Healthcare-Associated Infections.  Washington:  U. S. Department of Health and Human Services, 2009.

Pulse Report 2009. Safety Culture: Staff Perspectives on American Health Care.  South Bend, IN:  Press Ganey, 2009.

Krause, T., and Hidley, J.  Taking the Lead in Patient Safety:  How Healthcare Leaders Influence Behavior and Create Cultue.  Hoboken, NJ:  John Wiley and Sons, Inc., 2009.  (WX 185 K91t 2009).

Parente, S., and McCullough, J.  Health information technology and patient safety: evidence from panel dataHealth Affairs.  28(2):357-360, 2009.

Patient Safety Tools for Physician Practices.  Englewood, CO:  Medical Group Managment Association, 2003-2009.

Sadler, B., and others.  White Paper. Using Evidence-Based Environmental Design to Enhance Safety and Quality-FREE.  Cambridge, MA:  Institute for Healthcare Improvement, 2009.

Risk Management Pearls for Medication Safety.  Chicago:  American Society for Healthcare Risk Management, 209.  (QZ 42 R595m 2009).

Voorhis, K., and Willis, T.  Implementing a pediatric rapid response system to improve quality and patient safetyPediatric Clinics of North America.  56:919-933, 2009. 

Birk, S. Creating a culture of safety: why CEOs hold the key to improved outcomes. World Hospitals and Health Services. 45(2):5-7, 2009.

Leotsakos, A., and others. High 5s: addressing excellence in patient safety. World Hospitals and Health Services. 45(2):19-22, 2009.

Jeffs, L., and others.  Nursing leaders’ accountability to narrow the safety chasm: insights and implications from the collective evidence base on healthcare safety.  Nursing Leadership.  22(1):86-98, 2009.

Johnstone, M-J, and Kanitsaki, O.  Engaging patients as safety partners: some considerations for ensuring a culturally and linguistically appropriate approach.  Health Policy.  90(1):1-7, 2009.

Mountain, S., and others.  Effect of Ambient Workload in the Intensive Care Unit on Mortality and Time to Discharge Alive.  Healthcare Quarterly.  12(Special Issue), 2009.

Frankel, A., and others, editors.  Essential Guide for Patient Safety Officers.  Oakbrook Terrace, IL:  Joint Commission Resources, 2009.  (WX 185 E78g 2009).

Infection Prevention and Control Issues in the Environment of Care.  2nd ed.  Oakbrook Terrace, IL:  Joint Commission Resources, 2009.  (WX 167 I43e 2009).

National Healthcare Quality Report.  Rockville, MD : Agency for Healthcare Research & Quality, 2009.

King, S.  Josie's Story.  New York:  Atlantic Monthly Press, 2009.  (WX 153 K54j 2009).

Medication Reconciliation Handbook.  2nd ed.  Oakbrook Terrace, IL:  Joint Commission Resources, 2009.  (QV 38 M489 2009).

Patients as Partners in the Infection Prevention and Control Process.  Oakbrook Terrace, IL:  Joint Commissions Resources, 2009.  (WC 195 P298 2009). 

Meeting the Joint Commission's Infection Prevention and Control Requirements:  A Priority Focus Area.  Oakbrook Terrace, IL:  Joint Commission Resources, 2009.  (WX 167 M495 2009).

Leswick, D., and others.  Computed Tomography Radiation Dose: A Primer for AdministratorsHealthcare Quarterly.  12(Special Issue), 2009.

McCusker, J., and others.  Safety of Discharge of Seniors from the Emergency Department to the CommunityHealthcare Quarterly.  12(Special Issue), 2009.

Ackroyd-Stolarz, S., and others.  Impact of Adverse Events on Hospital Disposition in Community-Dwelling Seniors Admitted to Acute CareHealthcare Quarterly.  12(Special Issue), 2009.

Doran, D., and others.  Identification of Safety Outcomes for Canadian Home Care Clients: Evidence from the Resident Assessment Instrument - Home Care reporting system concerning emergency room visitsHealthcare Quarterly.  12(Special Issue), 2009.

Carvalho, C., Borycki, E., and Kushniruk, A.   Ensuring the Safety of Health Information Systems: Using Heuristics for Patient SafetyHealthcare Quarterly.  12(Special Issue), 2009.

O’Hagan, J., and others.  Self-Reported Medical Errors in Seven Countries: Implications for CanadaHealthcare Quarterly.  12(Special Issue), 2009.

Przybysz, R., Heather, D., and Leeb, K.   Falls among Top Reasons for Transfers from Continuing Care to Acute Care Hospitals in CanadaHealthcare Quarterly.  12(Special Issue), 2009.

Cafazzo, J., and others.  Human Factors Perspectives on a Systemic Approach to Ensuring a Safer Medication Delivery ProcessHealthcare Quarterly.  12(Special Issue), 2009.

Jeffs, L., and others.  Building Clinical and Organizational Resilience to Reconcile Safety Threats, Tensions and Trade-Offs: Insights from Theory and EvidenceHealthcare Quarterly.  12(Special Issue), 2009.

Tezak, B., and others.  Looking Ahead: The Use of Prospective Analysis to Improve the Quality and Safety of CareHealthcare Quarterly.  12(Special Issue), 2009.

Askeland, R., and others.  Enhancing Transfusion Safety with an Innovative Bar-Code-Based Tracking SystemHealthcare Quarterly.  12(Special Issue), 2009.

Borycki, E., and others.  Toward an Integrated Simulation Approach for Predicting and Preventing Technology-Induced Errors in Healthcare: Implications for Healthcare Decision-MakersHealthcare Quarterly.  12(Special Issue), 2009.

Lang, A., and others.  Home Care Safety Perspectives from Clients, Family Members, Caregivers and Paid ProvidersHealthcare Quarterly.  12(Special Issue), 2009.

Coffey, M., and others.  Implementation of Admission Medication Reconciliation at Two Academic Health Sciences Centres: Challenges and Success FactorsHealthcare Quarterly.  12(Special Issue), 2009.

Plante-Jenkins, C., and Belu, F.  Hand Hygiene: Seeing Is BelievingHealthcare Quarterly.  12(Special Issue), 2009.

Jackson, C., and others.  Improving Communication of Critical Test Results in a Pediatric Academic Setting: Key Lessons in Achieving and Sustaining Positive OutcomesHealthcare Quarterly.  12(Special Issue), 2009.

Soo, S., Whitney, B., and Baker, G.   Role of Champions in the Implementation of Patient Safety Practice ChangeHealthcare Quarterly.  12(Special Issue), 2009.

Griffin, F., and Resar, R. White Papers: 13. IHI Global Trigger Tool for Measuring Adverse Events. Cambridge, Ma: Institute for Healthcare Improvement. 2009. 

Hurdowar, A., and others.  Compliance with a Pediatric Clinical Practice Guideline for Intravenous Fluid and Electrolyte AdministrationHealthcare Quarterly.  12(Special Issue), 2009.

Morriss, F., and others.  "Nurses Don't Hate Change" - Survey of nurses in a neonatal intensive care unit regarding the implementation, use and effectiveness of a bar code medication administration systemHealthcare Quarterly.  12(Special Issue), 2009.

O'Beirne, M., and Sterling, P.  Medical Safety and Community Practice: Necessary Elements and Barriers to Implement a Safety Learning SystemHealthcare Quarterly.  12(Special Issue), 2009.

Cochrane, D., and others.  Establishing a Provincial Patient Safety and Learning System: Pilot Project Results and Lessons LearnedHealthcare Quarterly.  12(Special Issue), 2009.

Ginsburg, L., and others.  Categorizing Errors and Adverse Events for Learning: A Provider PerspectiveHealthcare Quarterly.  12(Special Issue), 2009.

Blais, R.,François, C., and Rousseau, L.   TOCSIN: A Proposed Dashboard of Indicators to Control Healthcare-Associated InfectionsHealthcare Quarterly.  12(Special Issue), 2009.

Croskerry, P.  Context Is Everything or How Could I Have Been That Stupid?  Healthcare Quarterly.  12(Special Issue), 2009.

Thompson, C., and Yang, H.  Nurses' Decisions, Irreducible Uncertainty and Maximizing Nurses' Contribution to Patient SafetyHealthcare Quarterly.  12(Special Issue), 2009.  

Wakefield, D., and Wakefield, B.  Are verbal orders a threat to patient safety? Quality Safety in Health Care.  18: 165-168, 2009.

Wakefield, D., and others.  An exploratory study measuring verbal order content and context.  Quality Safety in Health Care.  18: 169-173, 2009.

Estabrooks, C., and others.  Effects of shift length on quality of patient care and health provider outcomes: systematic review.  Quality Safety in Health Care.  18: 181-188, 2009.

Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. Chicago, IL: Consumers Advancing Patient Safety; 2009. 

Latino, R.  Patient Safety:  The PROACT Root Cause Analysis Approach.  Boca Raton, FL: Taylor & Francis Group, 2009 ( WX 153 L357p  2009).

Morse, J. Preventing Patient Falls:  Establishing a Fall Intervention Program. New York: Springer Publishing Company, 2009. ( WX 185 M885pr  2009).

Improving America's Hospitals:  The Joint Commission's Annual Report on Quality and Safety.  Oakbrook Terrace, IL:  Joint Commission, 2009.

Huang, L.J.  Medication events: the experience of the Taiwan patient-safety reporting system (TPR).  World Hospitals and Health Services.  45(4):19-23, 2009.

Syed, S.B.  African partnerships for patient safety: a vehicle for enhancing patient [sic].  World Hospitals and Health Services.  45(4):11-14, 2009.

Godolphin, W.  Shared Decision-MakingHealthcare Quarterly.  12(Special Issue), 2009.

Osheroff, J.  Improving Medication Use and Outcomes with Clinical Decision Support.  Chicago:  Healthcare Information and Management Systems Society, 2009.  (WX 179 O82i 2009).

Review of Patient Safety for Children and Young People.  London, UK: National Patient Safety Agency, 2009.

Anderson, D.  Clinical and Financial Outcomes Due to Methicillin Resistant Staphylococcus aureus Surgical Site Infection: A Multi-Center Matched Outcomes Study. PLoS ONE 4(12): e8305, 2009.

First state specific healthcare associated infections summary data reportCDC.  Jan. – June 2009.

 

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