Scanning the Headlines: Patient Safety (Archive) 2011-2010

   

Updated on April 29, 2013

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Links to full-text articles are provided where available.
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McKinney, M.  Fighting fatigue: Joint Commission highlights dangers, offers solutions.  Modern Healthcare.  41(51):10, Dec. 19/26, 2011.

Carlson, J.  Hospitals still feel the heat of fire risks.  Modern Healthcare.  41(51):31, 34, Dec. 19/26, 2011.

Abu-Ramaileh, A.M., and others.  Evaluating and classifying pharmacists’ quality interventions in the emergency department.  American Journal of Health-System Pharmacy;68(23):2271-2275, Dec. 1, 2011.

Gleason, K., and Brake, H.  Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.  Rockville, MD:  Agency for Healthcare Research and Quality.  Dec. 2011.  http://www.ahrq.gov/qual/match/

Federico, F., and Conway, J. Planning for a clinical crisis: next steps. Healthcare Executive.  26(6):74-76, Nov/Dec., 2011.

Health IT and Patient Safety:  Building Safer Systems for Better Care. Washington:  Institute of Medicine of the National Academies.  Nov. 8, 2011.  http://iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx

Ko, H., Turner, T., and Finnigan, M.  Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness.  Health Services Research.  Nov. 2011.  http://www.biomedcentral.com/1472-6963/11/211

Huff, C.  Commanding safety.  Trustee.  Oct. 10, 2011.  http://www.trusteemag.com/trusteemag_app/jsp/articledisplay.jsp?dcrpath=TRUSTEEMAG/Article/data/10OCT2011/1110TRU_coverstory&domain=TRUSTEEMAG

Levinson, D.  Adverse Events in Hospitals:  Medicare's Responses to Alleged Serious Events.  Washington:  Department of Health and Human Services, Oct. 2011.  http://oig.hhs.gov/oei/reports/oei-01-08-00590.pdf

Abramson, E.L., and others.  Electronic prescribing within an electronic health record reduces ambulatory prescribing errors.  The Joint Commission Journal on Quality and Patient Safety;37(10):470-478, Oct. 2011.

DuPree, E., Anderson, R., and McEvoy, M.D.  Professionalism: a necessary ingredient in a culture of safety.  The Joint Commission Journal on Quality and Patient Safety;37(10):447-455, Oct. 2011.

Sidlow, R., and, Aggarwal, V.  “The MICU is full”: one hospital’s experience with an overflow triage policy.  The Joint Commission Journal on Quality and Patient Safety;37(10):456-460, Oct. 2011. 

Webster, A.  How the right words can deliver a 6-figure payoff.  HealthLeaders Media.  Sept. 14, 2011.http://www.healthleadersmedia.com/content/MAR-270910/How-the-Right-Words-Can-Deliver-a-6Figure-Payoff

Clark, C.  12 CA hospitals fined for immediate jeopardy violations.  HealthLeaders Media.  Sept. 8, 2011.  http://www.healthleadersmedia.com/content/LED-270657/12-CA-Hospitals-Fined-for-Immediate-Jeopardy-Violations

Commins, J.  Temp ER nurses a safety threat to patients, study shows.  HealthLeaders Media.  Aug. 30, 2011.  http://www.healthleadersmedia.com/content/NRS-270315/Temp-ER-Nurses-a-Safety-Threat-to-Patients##

Radiation risks of diagnostic imaging.  The Joint Commission.  Issue 47, Aug. 24, 2011.  http://www.jointcommission.org/assets/1/18/SEA_471.PDF

Influenza vaccination coverage among health-care personnel -- United States, 2010--11 influenza season.  Morbidity and Mortality Weekly Report (MMWR).  60(32):1073-1077, Aug. 19, 2011.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6032a1.htm?s_cid=mm6032a1_w

Researcher:  Medical device data could be target of hackers.  iHealthBeat.  Aug. 4, 2011.  http://www.ihealthbeat.org/articles/2011/8/4/researcher-medical-device-data-could-be-target-of-hackers.aspx

Nakhleh, R., and others.  Mislabeling of cases, specimens, blocks, and slides.  Archives of Pathology & Laboratory medicine.  Aug. 2011.  http://www.archivesofpathology.org/doi/pdf/10.5858/2010-0726-CPR

Hayden, A., Lanoue, E., and Still, C.  Design for reliability:  Barcoded medication administration.  Patient Safety and Quality in Healthcare.  July/Aug. 2011.  http://www.psqh.com/julyaugust-2011/908-design-for-reliability-barcoded-medication-administration.html

Gawande, A.  Atul Gawande:  The power of checklists.  H&HN.  July 27, 2011.  http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8960004717

Dunn, L.  Patient experience:  An increasingly critical hospital indicator.  Becker's Hospital Review.  July 14, 2011.  http://www.beckershospitalreview.com/hospital-financial-and-business-news/patient-experience-an-increasingly-critical-hospital-indicator.html

Too many abandon the "second victims" of medical errors. ISMP Medication Safety Alert! Acute Care Edition [Institute for Safe Medication Practices]. 16:1-3, July 14, 2011.  http://www.ismp.org/Newsletters/acutecare/articles/20110714.asp

Grayson, M.  Problem partners in patient safety.  H&HN.  July 11, 2011.  http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8570001712

Young, J., and others.  "July effect":  Impact of the academic year-end changeover on patient outcomes.  A systematic review.  Annals of Internal Medicine, July 11, 2011.  http://www.annals.org/content/early/2011/07/11/0003-4819-155-5-201109060-00354.long

Barach, P., and Philibert, I.  The July effect:  Fertile ground for systems improvement.  Annals of Internal Medicine, July 11, 2011.  http://www.annals.org/content/early/2011/07/12/0003-4819-155-5-201109060-00352.full

RTI International. Designing Consumer Reporting Systems for Patient Safety Events  Agency for Healthcare Research and Quality, Rockville, MD: Agency for July 2011. http://www.ahrq.gov/qual/consreporting/

Weinberg, J., and others.  An inpatient fall prevention initiative in a tertiary care hospital.  Joint Commission Journal on Quality and Patient Safety.  37(7):317-2AP, 314, July 2011.  http://www.ingentaconnect.com/content/jcaho/jcjqs/2011/00000037/00000007/art00004

Gawande, A.  Q&A with Atul Gawande, Part 1.  H&HN.  June 29, 2011.  http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=2060009056

Boodman, S.  Effort to end surgeries on wrong patient or body part falters.  Washington Post.  June 20, 2011.  http://www.kaiserhealthnews.org/Stories/2011/June/21/wrong-site-surgery-errors.aspx

Rodak, S.  13 of the most influential patient safety advocates in the United States.  Becker's Hospital Review.  June 14, 2011.  http://www.beckershospitalreview.com/lists/13-of-the-most-influential-patient-safety-advocates-in-the-united-states.html

Nanji, K., and others.  Errors associated with outpatient computerized prescribing systems.  Journal of Informatics in Health and Biomedicine.  June 9, 2011.  http://jamia.bmj.com/content/early/2011/06/09/amiajnl-2011-000205.short?q=w_jamia_ahead_tab

Trimbach, E.  Never again.  The role of design in preventing 'never events'.  Healthcare Financial Management.  June 6, 2011.  http://www.hfmmagazine.com/hfmmagazine_app/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/Article/data/06JUN2011/0611HFM_FEA_Planning&domain=HFMMAGAZINE

Coburn, A., and Gage-Croll, Z.  Improving Hospital Patient Safety Through Teamwork:  The Use of TeamSTEPPS in Critical Access Hospitals.  Policy Brief #21.  Flex Monitoring Team, June 2011.  http://flexmonitoring.org/documents/PolicyBrief21_TeamSTEPPS.pdf

Clancy, C.  Patient Safety and Medical Liability Reform:  Putting the Patient First. Rockville, MD:  Agency for Healthcare Research and Quality, June 2011.  http://www.ahrq.gov/news/commentaries/comptsafty.htm

Clancy, C.  Preventing healthcare-associated infections:  Initiating promising solutions and expanding proven ones.  Rockville, MD:  Agency for Healthcare Research and Quality, June 2011.  http://www.ahrq.gov/news/commentaries/comhais.htm

Butterfield, S., and others.  Understanding care transitions as a patient safety issue.  Patient Safety in Quality Healthcare.  8:29-33, May/June 2011.  http://www.psqh.com/mayjune-2011/838-understanding-care-transitions-as-a-patient-safety-issue.html

Frisina, M.  Patient safety expert:  Focus on behavior over processes.  H&HN.  May 16, 2011.  http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=3630008311

Minich-Poirshadi, K.  Putting patient-centered care into perspective.  HealthLeaders Media.  May 2, 2011 http://www.healthleadersmedia.com/content/FIN-265604/Putting-PatientCentered-Care-Into-Perspective

Bouldin, E.L.D., and others.  Falls among adult patients hospitalized in the United States: prevalence and trends.  Journal of Patient Safety;9(1):13-17, Mar. 2011. 

Cantlupe, J.  The drive to patient safety.  HealthLeaders Media.  May 2011.  http://content.hcpro.com/pdf/content/266092.pdf

Partnering to Heal: Teaming up Against Healthcare-Associated Infections. Washington:  U.S. Department of Health and Human Services, May 2011.  http://www.hhs.gov/ash/initiatives/hai/training/

Guide to Infection Prevention in Outpatient Settings:  Minimum Expectations for Safe Care.  Atlanta, GA:  Centers for Disease Control and Prevention.  Apr. 2011.  http://www.cdc.gov/HAI/pdfs/guidelines/Ambulatory-Care-04-2011.pdf

McCarthy, D., and Klein, S.  Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement.  New York:  Commowealth Fund, Mar. 15, 2011.  http://www.commonwealthfund.org/Content/Publications/Case-Studies/2011/Mar/Keeping-the-Commitment.aspx

Barnes, S., and Weaver, T.  Overview:  Infection prevention and control for computers in patient care areas.  Becker's ASCREVIEW, Mar. 7, 2011.  http://www.beckersasc.com/asc-accreditation-and-patient-safety/overview-infection-prevention-and-control-for-computers-in-patient-care-areas.html

Page, D.  Medication reconciliation only as good as the IT allows.  Most Wired H&HN.  Mar. 3, 2011.  http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2011/0311HHN_Fea_MostWired&domain=HHNMAG

Signature Leadership Series.  Health Care Leaders Action Guide:  Hospital Strategies for Reducing Preventable Mortality.  Chicago:  American Hospital Association, Mar. 2011.  www.hret.org/mortality/resources/mortality-reduction020111.pdf

McCarthy, D., and Klein, S.  Keeping the Commitment:  A Progress Report on Four Early Leaders in Patient Safety Improvement.  New York:  Commonwealth Fund, Mar. 2011.  http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Mar/1478_McCarthy_keeping_commitment_patient_safety_case_study_synthesis.pdf

That's the way we do things around here!  Your actions speak louder than words it comes to patient safety.  ISMP Medication Safety Alert!  Feb. 24, 2011.  http://www.ismp.org/Newsletters/acutecare/articles/20110224.asp

Kolwalczyk L. No easy solutions for alarm fatigue. Hospitals examine monitor overuse. Special report, part 2. Boston Globe, Feb. 14, 2011. http://www.boston.com/lifestyle/health/articles/2011/02/14/no_easy_solutions_for_alarm_fatigue/

Kolwalczyk L. Patient alarms often unheard, unheeded. The incessant din of beeping monitors can numb or distract hospital staff; the consequences can be deadly. Special report part 1. Boston Globe, Feb. 13, 2011. http://www.boston.com/lifestyle/health/articles/2011/02/13/patient_alarms_often_unheard_unheeded/?page=full 

Clark, C.  Risk of medical errors by ED doctors linked to interruptions.  HealthLeaders Media.  Feb. 7, 2011.  http://www.healthleadersmedia.com/content/QUA-262256/Risk-of-Medical-Errors-by-ED-Doctors-Linked-to-Interruptions

Clark, C.  Gawande on checklists: why don’t hospitals use them?  HealthLeaders Media, Feb. 3, 2011.  http://www.healthleadersmedia.com/content/QUA-262159/Gawande-on-Checklists-Why-Dont-Hospitals-Use-Them.html

Partnering With Patients and Families to Enhance Safety and Quality.  A Mini Toolkit.  Bethesda, MD:  Institute for Patient- and Family-Centered Care.  Feb. 2011.  http://www.ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf

2010 National Healthcare Quality Report.  Rockville, MD:  Agency for Healthcare Research and Quality.  Feb. 2011.  http://www.ahrq.gov/qual/nhqr10/nhqr10.pdf

Harrington L, Kennerly D, Johnson C. Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000-2009. Journal of Healthcare Management. 56(1):31-44, Jan-Feb 2011.

Sentinel event summary through December 31, 2010. Oak Brook Terrace, IL: Joint Commission, Jan. 26, 2011. http://www.jointcommission.org/sentinel_event_statistics_quarterly/  

Tarkan, L.  As doctors age, worries about their ability grow.  New York Times. Jan. 24, 2011.  http://www.nytimes.com/2011/01/25/health/25doctors.html?_r=2&scp=1&sq=Doctors%20Age&st=cse

Institute for Safe Medication Practices. Guidelines for timely medication administration: response to the CMS "30-minute rule."  ISMP Medication Safety Alert! Acute Care Edition.16:1-4, Jan 13, 2011.  http://www.ismp.org/newsletters/acutecare/articles/20110113.asp

Vlayen, A., and others.  Incidence and Preventability of Adverse Events Requiring Intensive Care Admission: a Systematic Review.  Wiley, Jan. 6, 2011.  http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2010.01612.x/abstract;jsessionid=C4BFB6FAE6FF016975E9BF36C7DB7BEB.d01t03

Ackroyd-Stolarz, S., and others.  The Association Between a Prolonged Stay in the Emergency Department and Adverse Events in Older Patients Admitted to Hospital: a Retrospective Cohort Study.  London, UK:  BMJ Quality & Safety.  Jan. 5, 2011.  http://qualitysafety.bmj.com/content/early/2011/01/04/bmjqs.2009.034926

Long, S., and others.  Qualities and Attributes of a Safe Practitioner: Identification of Safety Skills in Healthcare.  London, UK: BMJ Quality & Safety.  Jan. 4, 2011.  http://qualitysafety.bmj.com/content/early/2011/01/04/bmjqs.2010.043166

Liu C. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clinical Infectious Diseases.  53:285-322, Jan 2011. http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full

A Checklist for Implementing an Effective Checklist. Leadership e-Bulletin [Healthcare Financial Management Association], Jan. 2011.  http://www.hfma.org/Publications/Leadership-Publication/Archives/E-Bulletins/2011/January/A-Checklist-for-Implementing-an-Effective-Checklist/  

Resource List For Users of the AHRQ Hospital Survey on Patient Safety Culture.  Rockville,  MD:  Agency for Healthcare Research and Quality.  Jan. 2011.  http://www.ahrq.gov/qual/patientsafetyculture/hospimpptsaf.htm

Hunt, J., and Sine, D.  Converting Medical Surgical Units for Safe USE BY Psychiatric Patients: the Physical and Fiscal Risks.  Chicago, IL:  American Society for Healthcare Engineering, 2011. (WX 140 H941c 2011).

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.
Institute of Safe Medication Practices. 2011.
http://psnet.ahrq.gov/resource.aspx?resourceID=23882&sourceID=1&emailID=

 

The Richard and Hinda Rosenthal Lecture 2011: New Frontiers in Patient Safety.
Institute of Medicine. Washington, DC: The National Academies Press; 2011. http://psnet.ahrq.gov/resource.aspx?resourceID=23337&sourceID=1&emailID=5141

Report on the Burden of Endemic Health Care-Associated Infection Worldwide.   Switzerland:  World Health Organization, 2011.  http://whqlibdoc.who.int/publications/2011/9789241501507_eng.pdf

O'Grady, N., and others.  Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011.  Washington:  Department of Health and Human Services, 2011.  http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

Conway, J., and others.  Respectful Management of Serious Clinical Adverse Events.  Cambridge, MA:  Institute for Healthcare Improvement, 2011.  http://www.ihi.org/knowledge/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx

Kurz, M., and Tobin, W.  Engaging Minority Communities in Safer Healthcare.  Chestnut Hill, MA:  MITSS, 2011.  http://www.mitss.org/EMCISHfinal.pdf

Research in Ambulatory Patient Safety.  2000-2010:  A 10-Year Review.  Chicago:  American Medical Association.  2011.  http://www.ama-assn.org/resources/doc/ethics/research-ambulatory-patient-safety.pdf 

Celona, J., Driver, J., and Hall, E.  Value-driven ERM: making ERM an engine for simultaneous value creation and value protection.  Journal of Healthcare Risk Management;30(4):15-33, 2011.

Howe, L.  A review of the Office of Inspector General’s reports on adverse event identification and reporting.  Journal of Healthcare Risk Management;30(4):48-54, 2011.

Shepps, S., and Cardiff, K.  Patient safety:  a wake-up call.  Clinical Governance:  An International Journal.  16(2):148-158, 2011.  http://www.emeraldinsight.com/journals.htm?issn=1477-7274&volume=16&issue=2&articleid=1918087&show=abstract

Stremikis, K., Schoen, C., and Fryer, A.  A Call for Change:  The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.  Washington:  U.S. Department of Health and Human Services, 2011.  http://psnet.ahrq.gov/resource.aspx?resourceID=21864&sourceID=1&emailID=5141

O'Grady, N., Alexander, M., and Burns, L.  Guidelines for the prevention of intravascular catheter-related infections. 
et al; Healthcare Infection Control Practices Advisory Committee. American Journal of Infection Control.  52:e162-e193, 2011.  http://cid.oxfordjournals.org/content/52/9/e162.full.pdf

Shahian, D., and others. Variability in the Measurement of Hospital-wide Mortality Rates.  New England Journal of Medicine.  363:2530-2539, Dec. 23, 2010.  http://www.nejm.org/doi/full/10.1056/NEJMsa1006396

Freudenheim,, M.  Panel set to study safety of electronic patient data.  New York:  The New York Times.  Dec. 13, 2010.  http://www.nytimes.com/2010/12/14/business/14records.html?_r=1

Landrigan, C., and others.  Temporal trends in rates of patient harm resulting from medical care.  New England Journal of Medicine.  363(22):2124-2134, Dec. 2, 2010.  http://www.nejm.org/doi/pdf/10.1056/NEJMsa1004404

Commins, J.  Medical errors stubbornly common, studies find.  HealthLeaders Media.  Dec. 2, 2010.  http://www.healthleadersmedia.com/content/LED-259668/Medical-Errors-Stubbornly-Common-Studies-Find

Preventing Medication Errors: A $21 Billion Opportunity. Washington, DC: National Priorities Partnership and National Quality Forum; Dec. 2010.
http://jhupbooks.press.jhu.edu/ecom/MasterServlet/GetItemDetailsHandler?iN=9780801898044&qty=1&source=2&viewMode=3&  

Thomas, K. Hand hygiene surveillance gets a 21st-century makeover [electronic monitoring]. Hospitals & Health Networks, Dec. 2010. http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/12DEC2010/1210HHN_Inbox_infectioncontrol&domain=HHNMAG

Ly, D., and others. How Do Black-Serving Hospitals Perform on Patient Safety Indicators?: Implications for National Public Reporting and Pay-for-Performance. Medical Care.  48(12):1133-1137, Dec. 2010. http://journals.lww.com/lww-medicalcare/pages/articleviewer.aspx?year=2010&issue=12000&article=00014&type=abstract

Medication labeling in the perioperative setting. Joint Commission Perspectives on Patient Safety. 10(12):6-8, Dec. 2010.

Adair, L. Managing patient safety through NPSGs and employee performance. Radiology Management. 32(6):50-55, Nov./Dec. 2010.

Landrigan, C. P., and others. Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine. 363(22):2124-2134, Nov. 25, 2010.

Quest High Performing Hospitals: a Program of the Premier Health Alliance.  2010 Top Performing Hospitals. Washington, DC: Premier, Inc., Nov. 22, 2010.  http://www.premierinc.com/quality-safety/tools-services/quest/downloads/2010TopPerformers_%20FINAL.pdf

CT radiation overdoses caused by user error, FDA says.  HealthLeaders Media.  Nov. 16, 2010.  http://www.healthleadersmedia.com/content/QUA-259078/CT-Radiation-Overdoses-Caused-By-User-Error-FDA-Says##

Clark, C.  12 hospitals fined for 'immediate jeopardy' violations in CA.  HealthLeaders Media.  Nov 15, 2010.  http://www.healthleadersmedia.com/content/LED-259024/12-Hospitals-Fined-for-Immediate-Jeopardy-Violations-in-CA##

Lin, M., and others.  Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.  Journal of the American Medical Association.  304(18):2035-2041, Nov. 10, 2010.  http://jama.ama-assn.org/cgi/content/short/304/18/2035

Dykes, P. C., and others. Fall prevention in acute care hospitals: a randomized trial.  JAMA.  304(17):1912-1918, Nov. 3, 2010.

Greenwald, J. L, and others. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Joint Commission Journal on Quality and Patient Safety. 36(11):504-13, 481, Nov. 2010.

Miller, E. D. Using checklists to help ensure accountability in care. Joint Commission Journal on Quality and Patient Safety. 36(11):518, Nov. 2010.

Nursing M & M conference: help in healing from a serious event. OR Manager. 26(11):1, 6-7, Nov. 2010.

Woods, M. S. Effective handoff communication, part 2: standardizing processes throughout your organization. Joint Commission Perspectives on Patient Safety. 10(11):1, 3-5, Nov. 2010.

Moving your hospital to a new facility, part 2: patient safety on the move. Joint Commission Perspectives on Patient Safety. 10(11):6-8, Nov. 2010.

Alternative surgical site marking. Joint Commission Perspectives on Patient Safety. 10(11):9-11, Nov. 2010.

2011 Top 10 Health Technology Hazards. ECRI Institute, Nov. 2010. https://www.ecri.org/Forms/Pages/2011_Top_10_Technology_Hazards.aspx [free registration required]

EHR Safety Event Reporting System. iHealth Alliance, Nov. 2010.  http://www.ehrevent.org/

Silber, J.H., and others.  The Hospital Compare mortality model and the volume-outcome relationship.  Health Services Research;45(5, Part I):1148-1167, Oct. 2010.

Stahel, P., and others.  Wrong-site and wrong-patient procedures in the universal protocol era.  Archives of Surgery. 145(10):978-984, Oct. 2010.  http://archsurg.ama-assn.org/cgi/content/short/145/10/978

In Conversation with…Peter J. Pronovost, MD, PhD [checklists]. AHRQ WebM&M, Perspectives on Safety, Oct. 2010. http://webmm.ahrq.gov/perspective.aspx?perspectiveID=91

McLaughlin, A. What makes a good checklist. AHRQ WebM&M, Perspectives on Safety, Oct. 2010.  http://webmm.ahrq.gov/perspective.aspx?perspectiveID=92

Wiedermann, L. A.  CPOE lessons learned. Journal of AHIMA. 81(10):54-55, 64, Oct. 2010.

Kendall-Gallagher, D., and Blegen, M. A. Competence and certification of registered nurses and safety of patients in intensive care units.  Journal of Nursing Administration. 40(20):S68-S75, Oct. 2010.

Moulton, C. A., and others. Slowing down to stay out of trouble in the operating room: remaining attentive in automaticity. Academic Medicine.  85(10):1571-7, Oct. 2010.

Nash, M., and others. Leveraging information technology to drive improvement  in patient satisfaction. Journal for Healthcare Quality. 32(5):30-40, Sept.-Oct. 2010.

Grant, M.  Dennis Quaid's Quest AARP The Magazine.  53:48-51,90-91, Sept./Oct. 2010.

Clark, C.  A call for standardized infection detection practices.  HealthLeaders Media.  Sept. 29, 2010.  http://www.healthleadersmedia.com/content/COM-257078/A-Call-for-Standardized-Infection-Detection-Practices

Demonstrating return on investment for infection prevention and control. Pennsylvania Patient Safety Advisory 7(3):102-7, Sept. 2010.  http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/102.aspx  

Special report: 2011 National Patient Safety Goals. The official, approved goals and helpful solutions for meeting them. Joint Commission Perspectives on Patient Safety. 10(9):1-15, Sept. 2010.

Howard, J., and others. New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature. Journal of Patient Safety. 6(3):147-152, Sept. 2010.

Whitehurst, J. M., and others. Tailoring “best of breed” safety classification for patient fall voluntary disclosure.  Journal of Patient Safety. 6(3):192-198, Sept. 2010.

Semel, M. E., and others. Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals. Health Affairs. 29(9):1593-9, Sept. 2010.

Wachter, R. M. Why diagnostic errors don't get any respect--and what can be done about them. Health Affairs. 29(9):1605-10, Sept. 2010.

Kirch, D. G., and Boysen, P. G. Changing the culture in medical education to teach patient safety. Health Affairs. 29(9):1600-4, Sept. 2010.

Diagnostic error in acute care. Pennsylvania Patient Safety Advisory7(3):76-86, Sept. 2010.  http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/76.aspx

State-sponsored programs help PA hospitals reduce HAIs.  Healthcare Benchmarks and Quality Improvement. 17(9):97-100, Sept. 2010.

Physicians use checklists for quality DP [discharge planning]. Healthcare Benchmarks and Quality Improvement. 17(9):105-107, Sept. 2010.

State-sponsored programs help PA hospitals reduce HAIs.  Healthcare Benchmarks and Quality Improvement. 17(9):97-100, Sept. 2010.

Physicians use checklists for quality DP [discharge planning]. Healthcare Benchmarks and Quality Improvement. 17(9):105-107, Sept. 2010.

Special report: 2011 National Patient Safety Goals. The official, approved goals and helpful solutions for meeting them. Joint Commission Perspectives on Patient Safety. 10(9):1-15, Sept. 2010.

Martin, K. Take flight with patient safety. Provider. 36(9):51-54, Sept. 2010.

Levtzion-Korach, O., and others. Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.  Joint Commission Journal on Quality and Patient Safety. 36(9):402-410, Sept. 2010.

Hamman, W. R., and others. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward. Quality Management in Health Care. 19(3):226-30, July-Sept. 2010.

Walston, S, L,, and others. The impact of information technology and organizational focus on the visibility of patient care errors. Quality Management in Health Care. 19(3):248-58, July-Sept. 2010.

Peshek, S. C., Cubera, K., and Gleespen, L. The use of interactive computerized order sets to improve outcomes. Quality Management in Health Care. 19(3):239-47, July-Sept. 2010.

Hamman, W. R., and others. Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward. Quality Management in Health Care. 19(3):226-30, July-Sept. 2010.

Peshek, S. C., Cubera, K., and Gleespen, L. The use of interactive computerized order sets to improve outcomes. Quality Management in Health Care. 19(3):239-47, July-Sept. 2010.

Walston, S, L,, and others. The impact of information technology and organizational focus on the visibility of patient care errors. Quality Management in Health Care. 19(3):248-58, July-Sept. 2010.

Hospitals in Pursuit of Excellence. Patient safety, including case studies. Chicago:  American Hospital Association, accessed Aug. 31, 2010.  

Hospitals in Pursuit of Excellence. Medication management, including case studies. Chicago:  American Hospital Association, accessed Aug. 31, 2010.  

Hospitals in Pursuit of Excellence. Health care acquired infections, including case studies. Chicago:  American Hospital Association, accessed Aug. 31, 2010.  

Simmons, J.  ACOG releases guidance on surgical errorsHealthLeaders Media.  Aug. 25, 2010.

Simmons, J. MRSA-resistant 'paint' kills bacteriaHealthLeaders Media.  Aug. 18, 2010.

Clark, C.  99% of CA UTIs incorrectly coded, study saysHealthLeaders Media.  Aug. 17, 2010.

Clark, C.  1 in 2 catheter-linked UTIs avoidable, study saysHealthLeaders Media.  Aug. 17, 2010.

Clark, C.  4 good news stories on HAI, and a bonus.   HealthLeaders Media.  Aug. 11, 2010.

Clark, C.  APIC: automated surveillance prevents HAIsHealthLeaders Media.  Aug. 6, 2010.

Sweeney, E.  Hospitals at risk for waterborne diseasesHealthLeaders Media.  Aug. 2, 2010.

Retained guidewires: on the rise? Patient Safety E-lerts [ECRI Institute], Aug. 2010. https://www.ecri.org/Forms/Pages/PSO_E-lert.aspx

Lucado, J., and others.  Adult Hospital Stays with Infections Due to Medical Care, 2007. Statistical Brief #94.  Rockville, MD:  Agency for Healthcare Research and Quality,  Aug. 2010.

Landry, C.S., and others.  From scalpel to console: a suggested model for surgical skill acquisition.  Bulletin of the American College of Surgeons.  95(8):20-24, Aug. 2010.

Looking at sentinel events along the continuum of patient safety.  The Joint Commission Perspectives.  30(8):3-5, Aug. 2010.

Approved: no new national patient safety goals, only minor revisions for 2011: SSP still considering medication reconciliation.  The Joint Commission Perspectives.  30(8):6-7, Aug. 2010.

Case study: Providence Regional Medical Center improves surgical safety. Joint Commission Perspectives on Patient Safety. 10(8):1-3, 4, 11, Aug. 2010.

Case study: Mount Sinai Hospital achieves zero CLABSI rate. Joint Commission Perspectives on Patient Safety. 10(8):5-7, Aug. 2010.

Case study: Providence Regional Medical Center improves surgical safety. Joint Commission Perspectives on Patient Safety. 10(8):1-3, 4, 11, Aug. 2010.

Case study: Mount Sinai Hospital achieves zero CLABSI rate. Joint Commission Perspectives on Patient Safety. 10(8):5-7, Aug. 2010.

Llewellyn, A. Getting back to the ABCs of patient safety. Supply Chain Strategies & Solutions. :1, 3,  July/Aug. 2010.

Oles, R. Hospitals & suppliers achieving immediate benefits as a part of data standardization project to improve patient safety and reduce costs. Supply Chain Strategies & Solutions. :4-5,  July/Aug. 2010.

Llewellyn, A. Getting back to the ABCs of patient safety. Supply Chain Strategies & Solutions. :1, 3,  July/Aug. 2010.

Oles, R. Hospitals & suppliers achieving immediate benefits as a part of data standardization project to improve patient safety and reduce costs. Supply Chain Strategies & Solutions. :4-5,  July/Aug. 2010.

Murphey, S.  Safe patient handling in diagnostic imaging.  Radiology Management.  32(4):46-52, July/Aug. 2010.

Huang, L., Norman, D., and Chen, R.  Addressing hospital-wide patient safety initiatives with high-fidelity simulation.  PEJ. Physician Executive Journal.  36(4):34-39, July/Aug. 2010.

Duffy, B.  First, protect the patient from harm: applying adult learning principles to patient safety.  Patient Safety of Quality in Healthcare.  7:32-36, July/Aug. 2010.

Dolan, P.  Computerized order entry systems may miss medication errors.  Amednews.com.  July 19, 2010.

Karash, J.  Hospitals Step Up Fight. Will It Be EnoughHospitals & Health Networks Magazine.  July 15, 2010.

DesRoches, C., and others.  Physcian’s perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.  Journal of the American Medical Association.  304 (2): 187-193 July 14,2010.

Clark, C.  Failure in Central Line Infection Prevention, Survey SaysHealthLeaders Media.  July 14, 2010.

Comak, H.  CPOES miss 1 in 3 potentially fatal medication ordersHealthLeaders Media, July 1, 2010.

Spencer, A., Sward, D., and Ward, J.  Lessons from the Pioneers: Reporting Healthcare-Associated Infections.  Washington:  National Conference of State Legislatures, July 2010.

Campbell, E. G., and others. Patient safety climate in hospitals: act locally on variation across units. Joint Commission Journal on Quality and Patient Safety. 36(7):319-326, July 2010.

ED pharmacy program has quality benefits.  Healthcare Benchmarks and Quality Improvement.  17(7):83-84, July 2010.

Stulberg, J., and others.  Adherence to Surgical Care Improvement Project Measures and the Association with Postoperative Infections.  The Journal of the American Medical Association.  303 (24): 2479-2485  June 23-30, 2010.

Nasca, T., Day, S., Amis, E., Jr; for ACGME Duty Hours Task Force. The new recommendations on duty hours from the ACGME Task Force New England Journal of Medicine, June 24, 2010.

Clark, C. Simple 'Three Bucket' Tool Helps Prevent Huge Cause of Inpatient Death [venous thromboembolism (VTE)]. HealthLeaders Media, June 9, 2010.

Murphy, D., and others. Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations. American Journal of Medical Quality. June 4, 2010 [Epub ahead of print].

Joint Commission. Preventing violence in the health care setting. Sentinel event alert. :45, June 3, 2010.

Zientek, D. M. Medical error, malpractice and complications: a moral geography.  HEC Forum. 22(2):145-57, June 2010.

Timmel, J., and others. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Joint Commission Journal on Quality and Patient Safety. 36(6):252-60, June 2010.   

The Power of Safety: State Reporting Provides Lessons in Reducing Harm, Improving Care.  Washington:  National Quality Forum, June 2010.

Ginsburg, L. R., and others, The relationship between organizational leadership for safety and learning from patient safety events. Health Services Research. 45(3):607-32, June 2010.

Leapfrog Group Report on CPOE Evaluation Tool Results June 2008 to January 2010. Executive Summary. Washington, DC: Leapfrog Group, June 2010.

Patient safety in emergency medicine: In conversation with Pat Croskerry, MD, Ph.D. Web M&M: Morbidity and Mortality Rounds on the Web, June 2010.

Sklar, D., and Crandall, C.  What do we know about emergency department safety? Web M&M: Morbidity and Mortality Rounds on the Web, June 2010.

2009 Technical Report Healthcare- Associated Infections (HAI) in Pennsylvania Hospitals.  PA:  Pennsylvania Department of Health.  June, 2010.

Is Reporting SCIP Measures Worth the EffortOutpatient Surgery Magazine.  June, 2010.

Doig, A.K., and Morse, J.M.  The hazards of using floor mats as a fall protection device at the bedside.  Journal of Patient Safety.  6(2):68-75, June 2010.

Wagner, D., and others.  The medication manager: results of a medication at the bedside pilot in a pediatric teaching institution.  Journal of Patient Safety.  6(2):76-79, June 2010.

Garcia-Williams, A., and others.  To ask or not to ask? The results of a formative assessment of a video empowering patients to ask their health care providers to perform hand hygiene.  Journal of Patient Safety.  6(2):80-85, June 2010.

Duthie, E.A.  Application of human error theory in case analysis of wrong procedures.  Journal of Patient Safety.  6(2):108-114, June 2010.

Young, J., Slebodnik, M., and Sands, L.  Bar code technology and medication administration error.  Journal of Patient Safety.  6(2):115-120, June 2010.

Singh, H., and others.  Ten strategies to improve management of abnormal test result alerts in the electronic health record.  Journal of Patient Safety.  6(2):121-123, June 2010.

From ‘worst’ to ‘first’ in pressure ulcer incidents.  Healthcare Benchmarks and Quality Improvement.  17(6):65-66, June 2010.

Pharmacists conduct med rec at admission: error rates decrease.  Healthcare Benchmarks and Quality Improvement.  17(6):70-72, June 2010.

Zientek, D. M. Medical error, malpractice and complications: a moral geography.  HEC Forum. 22(2):145-57, June 2010.

Veluswamy, R., and Price, R. I’ve fallen and I can’t get up: reducing the risk of patient falls. Physician Executive Journal. 36(3):50-53, May/June 2010.

Smillie, G. T. A culture of patient safety: crucial communication. Radiology Management.  32(3):9-13, May/June 2010.      

Lloyd, R.  Helping leaders blink correctly.  Healthcare Executive.  25(3):88, 90-91, May/June 2010.

Perez, B., and DiDona, T.  Assessing legislative potential to institute error transparency: a state comparison of malpractice claims rates.  Journal for Healthcare Quality.  32(3):36-41, May/June 2010.

Halbesleben, J. R., and others. Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Health Care Management Review. 35(2):124-33, Apr.-June 2010.

Singer, S. J., and others. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health Care Management Review. 35(2):134-46, Apr.-June 2010.   

Raymond, C.B., and others.  Reliability and validity of a survey to evaluate near attitudes and behaviours of pharmacy staff toward near misses.  Healthcare Management Forum.  23(1):32-37, Spring 2010.

Esporas, M., and Stuart, J.  The journey to zero.  Children’s Hospitals Today.  18:20-21, Spring 2010.

Blumenthal, A.  The culture of safety: what a difference a decade makes.  Children’s Hospitals Today.  18:22-24, Spring 2010.

Barnard, D., Carson, K.B., and Kaplan, J.  Can improvement be sustained?  Children’s Hospitals Today.  18:25, Spring 2010.

Berry, J., and Bengtson, R.  Improving perioperative performance.  Children’s Hospitals Today.  18:26-28, Spring 2010.

Towne, J. Improving culture improves patient safety. HR Pulse.:21-24, Spring 2010.

Brooks, P., and Sonnenschein, C. E-prescribing: where health information and patient care intersect. Journal of Healthcare Information Management. 24(2):53-59, Spring 2010.

Mccoy, J.  Put residents at the center of patient safety with house staff quality councils.  HealthLeaders Media.  May 28, 2010.

First State-Specific Healthcare-Associated Infections Summary Data Report. CDC's National Healthcare Safety Network (NHSN) January-June 2009.  Atlanta, GA:  CDC, May 25, 2010.

Poon, E. G., and others. Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine. 362(18):1698-707, May 6, 2010.

Bakhtiari, E.  Study : bar code technology reduces medication errors.  HealthLeaders Media.  May 6, 2010.

Cheung, K.  Whiteboards key to improved communicationHealthLeaders Media.  May 6, 2010.

Adopting evidence-based protocols, standards help hospital root out VAPAHA News.  46(9):6, May 3, 2010.

National Voluntary Consensus Standards for Medication Management.  Washington:  National Quality Forum, May 2010.

Dykes. P. C., Rothschild, J. M., and Hurley, A. C. Medical errors recovered by critical care nurses. Journal of Nursing Administration. 40(5):241-6, May 2010.

Elder, N., and others. The management of test results in primary care: does an electronic medical record make a difference?  Family Medicine. 42:327-333, May 2010.

RAND Corp study: better patient safety linked to fewer medical malpractice claims in California.  Medical Liability Monitor.  35(5):4, May 2010.

Interruptions while administering medical increases errors by nurses.  Medical Liability Monitor.  35(5):6, May 2010.

Terry, K.  Do you hold staff accountable for safety?  Trustee.  63(5):11-13, May 2010.

Grissinger, M.C., and others.  Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.  The Joint Commission Journal on Quality and Patient Safety.  36(5):195-202, May 2010.

Buckley, J.D., and others.  Linking residency training effectiveness to clinical outcomes: a quality improvement approach.  The Joint Commission Journal on Quality and Patient Safety.  36(5):203-208, May 2010.

Lighthall, G.K., Poon, T., and Harrison, T.K.  Using in situ simulation to improve in-hospital cardiopulmonary resuscitation.  The Joint Commission Journal on Quality and Patient Safety.  36(5):209-216, May 2010.

Hockey, P.M., and Bates, D.W.  Physicians’ identification of factors associated with quality in high- and low-performing hospitals.  The Joint Commission Journal on Quality and Patient Safety.  36(5):217-223, May 2010.

Stop “borrowing” medications. Protecting patients from harmful medication errors.  Joint Commission Perspectives on Patient Safety. 10(5):5-7, May 2010.

Clancy, C. Where Medical Errors Occur and How to Avoid Them [web video]. Rockville, MD: Agency for Healthcare Research and Quality, May 2010.

McKinney, M.  Can’t drive 55: some hospitals say the proposed new measures will be tough to implement.  Modern Healthcare.  40(17):6-7, Apr. 26, 2010.

Clark, C.  Better nurse patient ratios could save thousands of lives annually, says study.  HealthLeaders Media.  Apr. 20, 2010.

Getting to Zero : Strategies to Eliminate Central Line – Associated Bloodstream Infections.  New York: The Commonwealth Fund. Apr. 14, 2010

Metzger, J., and others. Mixed results in the safety performance of computerized physician order entry. Health Affairs. 29(4):655-663, Apr. 2010.                                          

Safe Practices for Better Healthcare- 2010.  Washington, DC: National Quality Forum. Apr. 2010.

Smetzer, J., and others. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety. 36(4):152-163, Apr. 2010.

Stelle, E., and Loughery, V. Health system sets “zero errors” as its goal for patient safety, quality. Healthcare Benchmarks and Quality Improvement. 17(4):37-41, Apr. 2010.                                           

Shaoon, D. Management/relationship issues impact patient safety efforts. Physician Executive. 36(2):22-28, Mar./Apr. 2010.

Safeek, Y. M., and May, P. T. Protocols, prompters, bundles, checklists, and triggers: synopsis of a preventable mortality reduction strategy.   Physician Executive. 36(2):30-33, Mar./Apr. 2010.     

Birk, S. The new quality-cost imperative: systemwide improvements can yield financial gains. Healthcare Executive. 25(2):14-24. Mar./Apr. 2010.

Michaels, A., and others.  Medication Errors in Acute Cardiovascular and Stroke Patients.  A Scientific Statement  From  the American Heart Association.  American Heart Association Circulation.  Mar. 22, 2010.

Simmons, J.  Hospitals could save millions by eliminating five hospital acquired conditions.  Marblehead, MA:  HealthLeaders Media,   Mar. 11,2010

Radiation Emitting Products.  White Paper:  Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.  Silver Spring, MD:  U.S. Food and Drug Administration. Mar. 3, 2010.

Leape, L. Perspectives on Health Care Reform: Transparency and Public Reporting Are Essential for a Safe Health Care System. New York, NY: The Commonwealth Fund, Mar. 2010.

Healthgrades Seventh Annual Patient Safety in American Hospitals Study.  Golden, CO: Health Grades Inc.  Mar. 2010

Chaffee, B. W., and Zimmerman, C. R. Developing and implementing clinical decision support for use in a computerized prescriber-order-entry system. American Journal of Health-System Pharmacy. 67(5):391- 399, Mar. 1, 2010.

Preventing maternal death. Joint Commission Perspectives. 30(3):7-9, Mar. 2010.

Sorra, J., and others.  Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report.  Rockville, MD: Agency for Healthcare Research and Quality; Mar. 2010. AHRQ Publication No. 10-0026.

Classen, D., Bates, D. W., and Denham, C. R. Meaningful use of computerized prescriber order entry. Journal of Patient Safety. 6(1):15-23, Mar. 2010.

George, W. W., and others. Leading in crisis: lessons for safety leaders. Journal of Patient Safety. 6(1):24-30, Mar. 2010.

Henderson, D., and others. Check a box, save a life: how student leadership is shaking up health care and driving a revolution in patient safety. Journal of Patient Safety. 6(1):43-47, Mar. 2010.

Denham, C. R. Greenlight issues for the CFO: investing in patient safety. Journal of Patient Safety. 6(1):52-56, Mar. 2010.

Henderson, J. G., and others. Reporting trends in a regional medication error data-sharing system. Health Care Management Science.  13(1):74-83, Mar. 2010.

Greising, C. H. Expanded rapid response program reduces mortality. Trustee. 63(3):27, Mar. 2010.

Loren, D. J., and others. Risk managers, physicians, and disclosure of harmful medical errors. Joint Commission Journal on Quality and Patient Safety. 36(3):101-108, Mar. 2010.

McDonnell, C., Laxer, R. M., and Roy, W. L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Joint Commission Journal on Quality and Patient Safety. 36(3):117-125, Mar. 2010.   

Levinson, D.  Adverse Events in Hospitals: Methods for Identifying Events.  Washington, DC: US Department of Health and Human Services, Office of the Inspector General; Mar. 2010. Report No. OEI-06-08-00221.

Rangachari, P.  Knowledge sharing and organizational learning in the context of hospital infection prevention.  Quality Management in Health Care.  19(1):34-46, Jan./Mar. 2010.

Glickman, S., and others.  Circulation cardiovascular qualiry and outcomes.  Journal of the American Heart Association.  3:188-195, Feb. 23, 2010. http://circoutcomes.ahajournals.org/content/3/2/188.full.pdf+html?sid=f524f512-957f-44e1-9f82-b5f20af12864

Eber, M., and others.  Clinical and economic outcomes attributable to health care associated sepsis and pneumoniaArchives of Internal Medicine. 170 (4) 347-353, Feb. 22, 2010.

Rhea, S.  Radiation gets extreme close-up.  Modern Healthcare.  40(7):12-13, Feb. 15, 2010.

Greene, L.  Curbing infections via electronic surveillanceMaterials Management in Health Care.  Feb. 2, 2010.

Terry, K.  Do you hold staff accountable for safety?  Hospitals & Health Networks.  Feb. 2, 2010.

Clark, C.  Surgeons still forgetting to remove objects from patients.  Marblehead, MA:  HealthLeaders Media.  Feb. 1, 2010.

Baker, S., Darin, M., and Lateef, O.  Multidisciplinary morbidity and mortality conferences: improving patient safety by modifying a medical tradition.  The Joint Commission Perspectives on Patient Safety.  10(2):8-10, Feb. 2010.

Are urinary catheters left in too long?  OR Manager.  26(2):21-22, Feb. 2010.

Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging.  Silver Spring,  MD:  U.S .Food and Drug Administration.  Feb. 9, 2010.  http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm199994.htm

Hall, D.  Med reconciliation: do the right thing.  Nursing Management.  41(2):32-36, Feb. 2010.

Morrison, C.  Effective obstetrical team communication.  Medical Liability Monitor.  35(2):8, Feb. 2010.

ProMutual launches new fetal heart monitor risk management program.  Medical Liability Monitor.  35(2):4, Feb. 2010.

Patient Safety Act: HHS Is in the Process of Implementing the Act, So Its Effectiveness Cannot Yet Be Evaluated. Washington, DC: Government Accountability Office, Jan. 29, 2010.

Kearns, S. Hospital creates electronic medication list to achieve consistency, help patients.  Marblehead, MA: HealthLeaders Media.  Jan. 29, 2010.

CDC to survey for hospital infectionsHealthData Management.  Jan. 27, 2010.

Gawande, A. The Checklist Manifesto: How to Get Things Right.  C-Span Book TV video, Jan. 16, 2010.

Survey shows recession has weakened patient safety net.  ISMP Medication Safety Alert! Acute Care Edition.  15:1-4, Jan. 14, 2010.

Origins of and solutions for neonatal medication-dispensing errors. American Journal of health-System Pharmacy. 67(1):49-57, Jan. 1, 2010.

Classen, D., Jaser, L., and Budnitz, D.  Adverse Drug Events Among Hospitalized Medicare Patients: Epidemiology and National Estimates from a New Approach to Surveillance.  Joint Commission Journal on Quality and Patient Safety, 36(1):12–21 and AP 1–9, Jan. 2010.

Rollins, G. Preventing wrong-site surgery. Materials Management in Health Care. 19(1): 20-22, Jan. 2010. 

Wachter, R.M.  Patient safety at ten: unmistakable progress, troubling gaps.  Health Affairs.  29(1):165-173, Jan. 2010.

Buxbaum, J.  Opportunities and Recommendations for State-Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.  Washington:  National Academy for State Health Policy, Jan. 2010.

Adverse Health Events in Minnesota: Sixth Annual Public Report.  St. Paul, MN: Minnesota Department of Health, Jan. 2010.

Patient photos help reduce hospital's medication errorsStrategies for Nurse Managers.com.  Jan. 2010.

Wide-ranging collaborative drives improvement in patient safety. Healthcare Benchmarks and Quality Improvement. 17(1):1-5, Jan. 2010.

Hand-washing compliance goes from 33% to 95%. Healthcare Benchmarks and Quality Improvement. 17(1):5-6, Jan. 2010.

Classen, D. C., Jaser, L., and Budnitz, D. S. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Joint Commission Journal on Quality and Patient Safety. 36(1):12-21, Jan. 2010.

Wrong implants a theme in errors. OR Manager. 26(1):5-6, Jan. 2010.

Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care.  Washington:  National Quality Forum, Jan. 2010.

Safe Practices for Better Healthcare-2010 Update.:  A Consensus Report.  Washington:  National Quality Forum, 2010.  (WX 153 S128 2010).

Crist, J.  Never say never: never events in medicine.  Health Matrix;20(2):437-465, 2010.

Research Projects in Health: The Economic Measurement of Medical Errors.  Schaumburg, IL:  SOA, 2010.

Chasing Zero: Winning the War on Healthcare Harm [video].  Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

Jha, A., and others.  Patient safety research: an overview of the global evidence. Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. Quality Safety in Health Care. 19:42-47, 2010.

Davidoff, F.  Checklists and guidelines: imaging techniques for visualizing what to do.  Journal of American Medical Association. 304:206-207, 2010.

Olds, D., and Clarke, S.  The effect of work hours on adverse events and errors in health careJournal of Safety Research.  41:153-162, 2010.

Greenberg, M., and others.  Is better patient safety associated with less malpractice activity?  Rand Institute for Civil Justice.  2010.

2010 MPSC Directory of Solutions.  Elkridge, MD: Maryland Patient Safety Center, 2010.

How to Guide : Multidisciplinary Rounds.  Cambridge, MA:  Institute for Healthcare Improvement.  2010.

Roberts, L., and others.  The Role of the National Quality Forum in the Quest for Transparency in U.S. Hospitals Patient Safety Performance.  Rockville, MD: Agency for Healthcare Research and Quality. 2010.

Unmet  Needs : Teaching Physicians to Provide Safe Patient Care.  Boston, MA: National Patient Safety Foundation.  2010.

On the Cusp: Stop HAI; a National Implementation of the Comprehensive Unit-Based Safety Program to Eliminate Health-Care Acquired Infections. Health Research & Educational Trust, Johns Hopkins University Quality and Safety Research Group, and the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality, 2010.

Arias, K., and Soule, B.  The APIC/JCR Infection Prevention and Control Workbook.  Oakbrook Terrace, IL:  Joint Commission Resources, 2010. (WX 167 A6421 2010). 

Patient Safety in the Intensive Care Unit.  Oakbrook Terrace,  IL: Joint Commission Resources, 2010. (WX 218 P298s 2010).

Toolkit for Preventing Health Care Associated Infections.  Oakbrook Terrace,  IL : Joint Commission Resources, 2010. (WX 167 T671 2010). 

Gawande, A.  Checklist Manifesto:  How to Get Things Right.  New York:  Henry Holt and Company, LLC, 2010.  (W 21 G284c 2010).

Meeting the Joint Commission's 2010 National Patient Safety Goals.  Oakbrook Terrace, IL:  Joint Commission Resources, 2010.  (WX 153 M495 2010).

Nurse's Role in Infection Prevention and Control.  Oakbrook Terrace, IL:  Joint Commission Resources, 2010.  (WY 153 N974 2010).

Scheurer, D., editor.  The Role of Hospitalists in Patient Safety.  Oakbrook Terrace, IL:  Joint Commission Resources, 2010.  (WX 203 R745 2010).

The faces of medical error...from tears to transparency [video series]. San Francisco: Empowered Patient Coalition; 2010.

Krug, S., editor.  Pediatric Patient Safety in the Emergency Department.  Oakbrook Terrace, IL:  Joint Commission Resources, 2010.  (WS 205 P43 2010).  (Includes CD-Rom).

Bunting, R. F., Jr. Calculating the frequency of serious reportable adverse events and hospital-acquired conditions. Journal of Healthcare Risk Management. 30(1):5-22, 2010.

Shreve, J., and others. The Economic Measurement of Medical Errors. Schaumburg, IL: Society of Actuaries, 2010.

Wachter, R.  Why diagnostic errors don't get any respect-and what can be done about them.  Health Affairs.  29(9):1605-1610, 2010.  http://content.healthaffairs.org/cgi/content/abstract/29/9/1605

Kirch, D., and Boysen, P.  Changing the culture in medical education to teach patient safety.  Health Affairs.  29(9);1600-1604, 2010.  http://content.healthaffairs.org/cgi/content/abstract/29/9/1600

Semel, M., and others.  Adopting a surgical safety checklist could save money and improve the quality of care in U.S. hospitals.  Health Affairs.  29(9):1593-1599, 2010.   http://content.healthaffairs.org/cgi/content/abstract/29/9/1593

Bunting, R. F., Jr. Calculating the frequency of serious reportable adverse events and hospital-acquired conditions. Journal of Healthcare Risk Management. 30(1):5-22, 2010.

Shreve, J., and others. The Economic Measurement of Medical Errors. Schaumburg, IL: Society of Actuaries, 2010.  http://www.soa.org/research/health/research-econ-measurement.aspx

Trowbridge, R., and Salvador, D. Addressing diagnostic errors: an institutional approach.  Focus on Patient Safety.  13(3):1-2,5, 2010.  http://www.npsf.org/paf/npsfp/fo/pdf/Focus%20v13-3-2010.pdf

Cardo, D., and others. Moving toward elimination of healthcare-associated infections: A call to action [by Association for Professionals in Infection Control and Epidemiology, Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, Association of State and Territorial Health Officials, Council of State and Territorial Epidemiologists, Pediatric Infectious Diseases Society, and Centers for Disease Control and Prevention.  American Journal of Infection Control, prepublication 2010.  http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/RegulatoryIssues/CDC/AJIC_Elimin.pdf

Andreoli, A., and others.  Using sbar to communicate falls risk and management in inter-professional rehabilitation teams.  Healthcare Quarterly.  13(Sp): 94-101, 2010.  http://www.longwoods.com/content/21973

Chagpar, A., and others.  Challenges of hand hygiene in healthcare: the development of a tool kit to create supportive processes and environments.  Healthcare Quarterly.  13(Sp): 59-66, 2010.  http://www.longwoods.com/content/21968

Conway, J., and others. Respectful management of serious clinical adverse events.  Institute for Healthcare Improvements, 2010. http://www.ihi.org/IHI/Results/WhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.htm

Gardam, M., and others.  Healthcare culture and the challenge of preventing healthcare-associated infections.  Healthcare Quarterly.  13(Sp): 116-120, 2010.  http://www.longwoods.com/content/21976

Hayes, C., and others.  Case study of physician leaders in quality and patient safety, and the development of a physician leadership network.  Healthcare Quarterly.  13(Sp): 68-73, 2010.  http://www.longwoods.com/content/21969

Crist, J.  Never say never: never events in medicine.  Health Matrix;20(2):437-465, 2010.

 

 

Law, M., and others.  Assessment of safety culture maturity in a hospital setting.  Healthcare Quarterly.  13 (Sp):  110-115, 2010.  http://www.longwoods.com/content/21975

Vermoch, K. L., and Bunting, R. F., Jr. Benchmarking patient- and family-centered care: Highlights from a study of practices in 26 academic medical centers. Journal of Healthcare Risk Management. 30(2):4-10, 2010.

Mistry, N., and others.  Optimizing physicians handover through the creation of a comprehensive minimum data set.  Healthcare Quarterly.  13(Sp) : 102-109, 2010.  http://www.longwoods.com/content/21974

Stevens, P., and others.  Building safer systems through critical occurrence reviews: nine years of learning.  Healthcare Quarterly.  13(Sp): 74-80, 2010.  http://www.longwoods.com/content/21970

 

Dietz, I., and others.  Medical errors and patient safety in palliative care: a review of current literature.  Journal of Palliative Medicine.  13 (12) : 2010.  http://www.liebertonline.com/doi/pdf/10.1089/jpm.2010.0228

Patient Safety in Primary Care. Vancouver, BC:  British Columbia Patient Safety & Quality Council.  2010.  http://www.bcpsqc.ca/pdf/Primary_Care_2010_english_FINAL.PDF

Speroff, T., and others.  Organizational culture; variation across hospitals and connection to patient safety climate.  International Journal of Healthcare Improvement.  19 (6) 2010.  http://qualitysafety.bmj.com/content/19/6/592

Zimmerman, R., and others.  Aiming for zero preventable deaths:  using death review to improve care and reduce harm.  Healthcare Quarterly.  13(Sp): 81-87, 2010.  http://www.longwoods.com/content/21971

Greene, L., and others.  Guide to the Elimination of Orthopedic Surgical Site Infections.  Washington:  APIC, 2010.  http://www.apic.org/downloads/ortho_guide.pdf

Aureden, K., and others.  Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings, 2nd ed.  Washington:  APIC, 2010.  http://www.apic.org/downloads/MRSA_elimination_guide_27030.pdf

 

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