Scanning the Headlines: Patient Safety (Archive) 2004-2001

Updated on January 24, 2013

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Links to full-text articles are provided where available.
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Computer Entry a Leading Cause of Medication Errors in U.S. Health Systems.  Rockville, MD:  United States Pharmacopeia, Dec. 20, 2004.


Evans, M.  Opening up files in Florida.  Modern Healthcare.  34(50):12, Dec. 13, 2004.

Rauber, C. Sutter averts 28,000 med errors through bar-coding. East Bay Business Times, Dec. 13, 2004.

VHA, Inc. VHA survey shows hospital infection control staff are spread too thin: opportunities for hospital-acquired infections occur, costing billions. Press Release, Dec. 7, 2004.

Adler, A., and Schukman, J.  The role of managed care in patient safety & error reduction.  Managed Care.  13(12):42-47, Dec. 2004.

Take steps to prevent anesthesia awareness, JCAHO says in alert.  OR Manager.  20(12):1, 8-9, Dec. 2004.

Preventive health for staff critical to patient safety.  Ed Management.  16(12):136-137, Dec. 2004.

Baier, R., Patry, G., and Gifford, D.  The business case for quality.  Provider.  30(12):41-42, Dec. 2004.

Eisenberg, J.  The faces of errors:  a case-based approach to educating providers, policymakers, and the public about patient safety.  Joint Commission Journal on Quality and Safety.  30(12):665-670, Dec. 2004.

Eisenberg, J.  "Keeping each patient safe":  quality safety teaching/learning packets.  Joint Commission Journal on Quality and Safety.  30(12):676-680, Dec. 2004.

Preventing medication errors: handwritten orders.  Quality Improvement Online.  Issue 2, Dec. 2004.

Berte, L.  Patient safety:  getting there from here.  Clinical Leadership & Management Review.  18(6):311-315, Nov./Dec. 2004.

Hoeltge, G.  The cost of patient safety.  Clinical Leadership & Management Review.  18(6):316-321, Nov./Dec. 2004.

Nichols, J., and others.  Reducing medical errors through barcoding at the point of care.  Clinical Leadership & Management Review.  18(6):328-334, Nov./Dec. 2004.

Johnson, P.  The contribution of proficiency testing to improving laboratory performance and ensuring quality patient care.  Clinical Leadership & Management Review.  18(6):335-341, Nov./Dec. 2004.

Dighe, A., and Laposata, M.  Making the laboratory a partner in patient safety.  Clinical Leadership & Management Review.  18(6):356-360, Nov./Dec. 2004.

Bissell, M.  Information systems and human error in the lab.  Clinical Leadership & Management Review.  18(6):349-355, Nov./Dec. 2004.

Smith, M.  Owning up:  tests that were not done were reported as normal and tests that were done were not reported at all.  The Physician Executive.  30(6):54-56, Nov./Dec. 2004.

Boxwala, A., and others.  Organization and representation of patient safety data:  current status and issues around generalizability and scalability.  Journal of the American Medical Informatics Association:  JAMIA.  11(6):468-478, Nov./Dec. 2004.

Talone, P.  Patient safety and the ministry.  Health Progress.  85(6):18-20, Nov./Dec. 2004.

O'Rouke, Fr.  Medical error:  some ethical concerns.  Health Progress.  85(6):28-31, Nov./Dec. 2004.

The "sentinel events" study.  Health Progress.  85(6):33-36, 62, Nov./Dec. 2004.

George, J., and Johnson, M.  A pilot program takes flight:  the North Carolina practitioner remediation and enhancement partnership experience.  Journal of Nursing Administration.  6(4):100-104, Oct./Dec. 2004.

Liff, B.  The structure processes, and outcomes of Banner Health's Corporate-wide strategy to improve health care quality.  Quality Management in Health Care.  13(4):264-277, Oct./Dec. 2004.

Altman, D., Clancy, C., and Blendon, R.  Improving patient safety-five years after the IOM. The New England Journal of Medicine.  351(20):2041-2043, Nov. 11, 2004.

Morrisey, J.  An umistakable approach.  Modern Healthcare.  34(44):28, Nov. 1, 2004.

Morrisey, J.  Patient safety proves elusive.  Modern Healthcare.  34(44):6-7, 24, 30-32, Nov. 1, 2004.

Feldstein, A., and others.  How to design computerized alerts to ensure safe prescribing practices.  Joint Commission Journal on Quality and Safety.  30(11):602-613, Nov. 2004.

Hamilton, K., and others.  Using variance analysis to detect hazards in a bar-code-assisted medication preparation process.  Joint Commission Journal on Quality and Safety.  30(11):622-628, Nov. 2004.

Wieman, T., and Wieman E.  A systems approach to error prevention in medicine.  Journal of Surgical Oncology.  88(3):115-121, Nov. 2004.

Solberg, L., and others.  Measuring patient safety in ambulatory care:  potential for identifying medical group drug-drug interaction rates using claims data.  The American Journal of Managed Care.  10(11):753-759, Nov. 2004.

National Survey on Consumers' Experiences With Patient Safety and Quality Information.  Menlo Park, CA:  The Kaiser Family Foundation, Nov. 2004.

Lockley, S., and others.  Effect of reducing interns' weekly work hours on sleep and attentional failures.  The New England Journal of Medicine.  351(18):1829-1837, Oct. 28, 2004.

Landrigan, C., and others.  Effect of reducing interns' work hours on serious medical errors in intensive care units.  The New England Journal of Medicine.  351(18):1838-1848, Oct. 28, 2004.

Millar, J, Mattke, S, and others: Selecting indicators for patient safety at the health systems level in OECD countries. OECD Health Technical Papers. 18, Oct. 28, 2004.

World Health Organization: World Alliance for Patient Safety: The launch of the World Alliance for Patient Safety, Washington, DC, USA -- October 27, 2004.

Fried, M., and others.  Identifying and reducing errors with surgical simulation.  Quality & Safety in Health Care.  13(Suppl. 1):i19-i26, Oct. 2004.

Winners announced for 2004 Eisenberg patient safety awards.  The Quality Letter for Healthcare Leaders.  16(10):15, Oct. 2004.

Yates, G., and others.  Sentara Norfolk General Hospital:  Accelerating improvement by focusing on building a culture of safety.  Joint Commission Journal on Quality and Safety.  30(10):534-542, Oct. 2004.

Paine, L., and others.  The Johns Hopkins Hospital:  identifying and addressing risks and safety issues.  Joint Commission Journal on Quality and Safety.  30(10):543-550, Oct. 2004.

Lindblad, B., Chilcott, J., and Rolls, L.  Mary Lanning Memorial Hospital:  communication is key.  Joint Commission Journal on Quality and Safety.  30(10):551-558, Oct. 2004.

Willeumier, D.  Advocate health care:  a systemwide approach to quality and safety.  Joint Commission Journal on Quality and Safety.  30(10):559-566, Oct. 2004.

Blair, R., editor.  Medication transformation:  pharmacists on the floor.  Health Management Technology.  25(10):26-33, Oct. 2004.

Donovan, J.  Data center upgrade essential to enhanced patient care.  Health Management Technology.  25(10):38-42, Oct. 2004.

Winterstein, A., and others.  Nature and causes of clinically significant medication errors in a tertiary care hospital.  American Journal of Health-System Pharmacy.  61(18):1908-1916, Sept. 15, 2004.

Study shows 12-hour shifts increase errors.  Healthcare Benchmarks and Quality Improvement.  11(9):105-106, Sept. 2004.

Davidson, G., and Riordan, C.  Keys to successful CPOE implementation.  Health Management Technology.  25(9):64-66, Sept. 2004.

Jeffe, D., and others.  Using focus groups to understand physicians' and nurses' perspectives on error reporting in hospitals.  Joint Commission Journal on Quality and Safety.  30(9);471-479, Sept. 2004.

Kennedy, A., and Littenberg, B.  A modified outpatient prescription form to reduce prescription errors.  Joint Commission Journal on Quality and Safety.  30(9);480-487, Sept. 2004.

Demiris, G., and others.  To telemedically err is human.  Joint Commission Journal on Quality and Safety.  30(9);521-527, Sept. 2004.

Burstin, H., and Wakefield, M.  The importance of safety and quality in rural America.  The Journal of Rural Health.  20(4):301-303, Fall 2004.

Wholey, D., and others.  The environmental context of patient safety and medical errors.  The Journal of Rural Health.  20(4):304-313, Fall 2004.

Coburn, A., and others.  Assuring rural hospital patient safety:  what should be the priorities.  The Journal of Rural Health.  20(4):314-326, Fall 2004.

Casey, M., and Moscovice, I.  Quality improvement strategies and best practices in critical access hospitals.  The Journal of Rural Health.  20(4):327-334, Fall 2004.

Jones, K., and others.  Translating research into practice:  voluntary reporting of medication errors in critical access hospitals.  The Journal of Rural Health.  20(4):335-343, Fall 2004.

Ward, M., and others.  What would be the effect of referral to high-volume hospitals in a largely rural state?  The Journal of Rural Health.  20(4):344-354, Fall 2004.

Westfall, J., and others.  Applied strategies for improving patient safety:  a comprehensive process to improve care in rural and frontier communities.  The Journal of Rural Health.  20(4):355-362, Fall 2004.

Wolf, R., and Serembus, J.  Medication errors:  ending the blame-game.  Nursing Management.  35(8):41-47, Aug. 2004.

Jacobs, B.  Hardly child's play:  implementing a pediatric-specific, integrated CPOE system.  Health Management Technology.  25(8):30-32, Aug. 2004.

The Joint Commission announces the 2004 national patient safety goals and requirements.  Joint Commission Perspectives.  24(8):1, 3, Aug. 2004.

Neil, R.  Bar coding won't be required by JCAHO as anticipated.  Materials Management in Health Care.  13(8):6, Aug. 2004.

Children in hospitals often have adverse events.  Healthcare Benchmarks and Quality Improvement.  11(8):94-95, Aug. 2004.

Shah, R., and others.  Classification and consequences of errors in otolaryngology.  Laryngoscope.  114(8):1322-1335, Aug. 2004.

Cohen, M., and others.  Implementing a hospitalwide patient safety program for cultural change.  Joint Commission Journal on Quality and Safety.  30(8):424-431, Aug. 2004.

Woodall, S.  Remote order entry and video verification:  reducing after-hours medication errors in a rural hospital.  Joint Commission Journal on Quality and Safety.  30(8):442-447, Aug. 2004.

Perry, S.  An overlooked alliance:  using human factors engineering to reduce patient harm.  Joint Commission Journal on Quality and Safety.  30(8):455-459, Aug. 2004.

Mound, T., editor.  Closing the communication loop:  using readback/hearback to support patient safety.  Joint Commission Journal on Quality and Safety.  30(8):460-464, Aug. 2004.

Liebman, C., and Hyman, C.  A mediation skills model to manage disclosure of errors and adverse events to patients.  Health Affairs.  23(4):22-32, July/Aug. 2004.

Meyers, S.  Data in, safety out.  Trustee.  57(7):12-19, July/Aug. 2004.

Mello, M.  Caring for patients in a malpractice crisis:  physician satisfaction and quality of care.  Health Affairs.  23(4):42-53, July/Aug. 2004.

Exploring the business case for improving the quality of health care for children.  Health Affairs.  23(4):159-166, July/Aug. 2004.

Poon, E., and others.  Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. Hospitals.  Health Affairs.  23(4):184-190, July/Aug. 2004.

Rogers, A., and others.  The working hours of hospital staff nurses and patient safety.  Health Affairs.  23(4):202-212, July/Aug. 2004.

Protti, D.  The role of information technology in patient safety:  Festina lente.  Healthcare Management Forum.  17(2):41-43, Summer 2004. 

Cahill, D., and Sternlieb, J.  Community hospital CPOE implementation:  the need for collaboration between nurse and physician informaticists.  Journal of Healthcare Information Management.  18(3):17-18, Summer 2004.

Wilson, L.  Maybe not a safety indicator.  Modern Healthcare.  34(30):6-10 Suppl., July 26, 2004.

CMS Needs Additional Authority to Adequately Oversee Patient Safety in Hospitals.  Washington, DC:  General Accounting Office, July 2004.

Poor communication:  root of most patient safety ills.  ED Management.  16(7):76-78, July 2004.

North Carolina hospital prepares for bar code implementation.  iHealthBeat.  June 4, 2004. 

Oregon to begin hospital error reporting program.  iHealthBeat.  June 4, 2004.

Landon B., and others.  Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study.  Annals of Internal Medicine. 140(11):887-96, June 1, 2004.

Prevent infant abductions with FMEA processes.  Hospital Peer Review.  29(6):77-8, June 2004.

Six Sigma gives leaders tools for improving processes in OR.  OR Manager. 20(6):1, 13-5, June 2004.

Six Sigma improves care, reduces hospitals' costs.  Hospital Case Management.  12(6):85-6, June 2004.

Zipperer, L.  Clinicians, librarians and patient safety:  opportunities for partnership.  Quality & Safety in Health Care.  13(3):218-222, June 2004.

Arah, O., and Klazinga, N.  How safe is the safety paradigm?  Quality & Safety in Health Care.  13(3):226-232, June 2004.

Bann, S., and Darzi, A.  A protocol for the reduction of surgical errors.  Quality & Safety in Health Care.  13(3):162-163, June 2004.

Walton, M.  Creating a "no blame" culture:  have we got the balance right?  Quality & Safety in Health Care.  13(3):163-164, June 2004.

Haglund, M.   Point-of-care protection.  Healthcare Informatics.  June 2004.

Miller, M., and Zhan, C.   Pediatric patient safety in hospitals: a national picture in 2000.  Pediatrics.  113(6):1741-1746, June 2004.

2003 sentinel event data.  Joint Commission Perspectives.  24(6):11, June 2004.

Darves, B.  Prescription for safety.  Healthleaders.  7(6):32-36, June 2004.

Vogt, T., and others.  The prevention index:  using technology to improve quality assessment.  Health Services Research.  39(3):511-529, June 2004.

Scanlon, M.  Computer physician order entry and the real world:  we're only humans.  Joint Commission Journal on Quality and Safety.  30(6):342-346, June 2004.

Chan, A.  Use of Six Sigma to improve pharmacist dispensing errors at an outpatient clinic.  American Journal of Medical Quality.  19(3):128-31, May/June 2004.

Walshe, K., and Shortell, S.  When things go wrong: how health care organizations deal with major failures.  Health Affairs (Millwood).  23(3):103-11, May/June 2004.

Pieper, S.  "Good to great" in healthcare: how some organizations are elevating their performance.  Healthcare Executive.  19(3):20-6, May/June 2004.

McGlynn, E.  There is no perfect health system.  Health Affairs (Millwood).  23(3):100-2, May/June 2004.

Johnson, K.  Keeping patients safe:  an analysis of organizational culture and caregiver training.  Journal of Healthcare Management.  49(3):171-179, May/June 2004.

Rabinowitz, E.  Patient safety requires systems, culture change.  AHIP Coverage. 

45(3):62-66, May/June 2004.

Potow, C.  Improving patient safety through simulation technology.  AHIP Coverage.  45(3):74-77, May/June 2004.

Hussey, P., and others.  How does the quality of care compare in five countries? Health Affairs.  23(3):89-99, May/June 2004.

Walshe, K., and Shortell, S.  When things go wrong:  how health care organizations deal with major failures.  Health Affairs.  23(3):103-111, May/June 2004.

Kerr, E., and others.  Profiling the quality of care in twelve communities:  results from the CQI Study.  Health Affairs.  23(3):247-256, May/June 2004.

Blendon, R., and others.  Confronting competing demands to improve quality:  a five-country hospital survey.  Health Affairs.  23(3):119-135, May/June 2004.

Walter, L., and others.  Pitfalls of converting practice guidelines into quality measures.  JAMA:  The Journal of the American Medical Association.  291(20):2466-2470, May 26, 2004.

Responding to tragic error:  lessons from Foothills Medical Centre.  CMAJ. 170(11):1659-1660, May 25, 2004.

The Canadian adverse events study:  the incidence of adverse events among hospital patients in Canada.  CMAJ.  170(11):1678-1686, May 25, 2004.

Nebeker, J., Barach, P., and Samore, M. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.  Annals of Internal Medicine. 140(10):795-801, May 18, 2004.

Mazor, K., and others. Health plan members' views about disclosure of medical errors.  Annals of Internal Medicine. 140(6):409-18, May 16, 2004.

Summaries for patients. The effects of telling patients about medical errors.  Annals of Internal Medicine. 140(6):I17, May 16, 2004.

Ohio health system to add CPOE.  iHealthBeat.  May 13, 2004.

Spath, P.  Use Baldrige criteria to advance excellence.  Hospital Peer Review.  29(5):69-72, May 2004.
Make these changes to improve safety.  Hospital Peer Review.  29(5):68-9, May 2004.

Twelve new measures proposed for quality initiative.  The Quality Letter for Healthcare Leaders.  16(5):10-11, May 2004.

Safety in mobility for patients and staff.  OR Manager.  20(5):12, May 2004.

Beusekom, M.  Reducing medical errors.  Healthcare Informatics.  21(5):40i-40vi, May 2004.

Be proactive:  improve patients' quality of life.  Hospital Home Health.  21(5):51-53, May 2004.

Clavin, T.   How you can protect yourself.  Parade.  May 23, 2004.

Nebeker, J., Barach, P., and Samore, M. Clarifying adverse drug events: a  clinician's guide to terminology, documentation, and reporting.  Annals of Internal Medicine. 140(10):795-801, May 18, 2004.

Mazor, K., and others. Health plan members' views about disclosure of medical

errors.  Annals of Internal Medicine. 140(6):409-18, May 16, 2004.

Summaries for patients. The effects of telling patients about medical errors.
Annals of Internal Medicine. 140(6):I17, May 16, 2004.

Avoid PCA errors with education.  Hospital Home Health.  21(5):56-57, May 2004.

Bond, W., and others.  Using simulation to instruct emergency medicine residents in cognitive forcing strategies.  Academic Medicine.  79(5):438-446, May 2004.

Bar coding at the bedside.  Health Management Technology.  25(5):42, 44, May 2004.

Cantrell, L.  Promoting safety, reducing falls.  Provider.  30(5):39-40, May 2004.

Swayne, B., and Salamalay, D.  Injecting excellence into the DNA of healthcare services. New initiatives can lead to breakthrough improvements via higher quality at lower costs.  Healthcare Management Forum.  17(1):29-31, Spring 2004.

Berta, W., and Baker, R.  Factors that impact the transfer and retention of best practices for reducing error in hospitals.  Health Care Management Review. 29(2):90-97, Apr./June 2004.

Morrissey, J.  Too much too soon?  [JCAHO's proposed 2007 deadline for

bedside bar-code technology].  Modern Healthcare.  34(17):6, 7, 16, Apr. 26, 2004.

Electronic Prescribing: Toward Maximum Value and Rapid Adoption.  Washington:  eHealth Initiative, Apr. 14, 2004.

Freudenheim, M.  Many hospitals resist computerized patient care.  The New York Times.  April 6, 2004. 

Pawlson, L., and O'Kane, M.  Malpractice prevention, patient safety, and quality of care: a critical linkage.  The American Journal of Managed Care.10(4):281-4, Apr. 2004.

Hospital executives get in middle of the action to improve patient safety.  GHA Today.  58(4):1, 4, Apr. 2004.

Setting safe standards.  Health Management Technology.  25(4):30-33, Apr. 2004.

Statement on patient safety principles for office-based surgery utilizing moderate sedation/analgesia, deep sedation/analgesia, or general anesthesia.  Bulletin of the American College of Surgeons.  89(4):32-34, Apr. 2004.

Weinger, M., and others.  Video capture of clinical care to enhance patient safety. Quality & Safety in Health Care.  13(2):136-144, Apr. 2004.

Ritter-Teitel, J.  Registered nurse hours worked per patient day.  The Journal of Nursing Administration (JONA).  34(4):167-169, Apr. 2004.

Batcheller, J., Burkman, K., and Armstrong, D. A practice model for patient safety.  Journal of Nursing Administration (JONA).  34(4):200-205, Apr. 2004.

Barlow, R.  Counterfeit combat:  chips raise the stakes in fighting fakes.  Healthcare Purchasing News.  28(4):14-15, Apr. 2004.

Center for Information Technology Leadership, Wellesley, MA.  Patient Safety in the Physician's Office:  Assessing the Value of Ambulatory CPOE.  Oakland, CA:  California HealthCare Foundation, Apr. 2004.

Hospitals call on safety coaches to draw game plan for compliance. Briefings on Patient Safety.  5(4):, Apr. 2004.

Phillips, R.  and others.  Learning from malpractice claims about negligent, adverse events in primary care in the United States.  Quality & Safety in Health Care.  13(2):121-6, Apr. 2004.

Brennan, T., and others.  Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I.  Quality & Safety in Health Care. 13(2):145-151, Apr. 2004.

Goel, A., MacLean, C., Walrath, D. Adapting root cause analysis to chronic medical conditions. Joint Commission Journal on Quality and Safety. 30(4):175-18, Apr. 2004.  

LeBlanc, F., and others.  A six sigma approach to maximizing productivity in the cardiac cath lab.  The Journal of Cardiovascular Management. 15(2):19-24, Mar./Apr. 2004.

Clark, A., and Houston, S.  Nosocomial infections. An issue of patient safety, Part 2.  Clinical Nurse Specialist CNS. 18(2):62-4, Mar./Apr. 2004.

Patient safety:  looking through the eyes of your patients.  Clinical Leadership &Management Review.  18(2):137-143, Mar./Apr. 2004.

Drazen, E., and Hansen, J.  The electronic patient safety net:  the digital transformation of patient care.  Healthplan.  45(2):52-56, Mar./Apr. 2004.

Ash, J., Berg, M., and Coiera, E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Journal of the American Medical Informatics Association: JAMIA. 11(2):104-112, Mar./Apr. 2004.  

Berger, R., and Kichak, J. Computerized physician order entry: helpful or harmful?

Journal of the American Medical Informatics Association: JAMIA.  11(2):100-103, Mar./Apr. 2004.  

Elder, N., Meulen, M., and Cassedy, A.  The identification of medical errors by family physicians during outpatient visits.  Annals of Family Medicine.  2:125-129, Mar./Apr. 2004.

Devers, K., Pham, H., and Liu G. What is driving hospitals' patient-safety efforts. Health Affairs.  23(2):103-115, Mar./Apr. 2004.

Hospital leaders leery of mandatory error reports.  USA Today.  Mar. 15, 2004.

Hawryluk, M.   FDA targets medication errors by requiring bar codes on drugs.  Mar. 15, 2004.

Pedersen, C., Schneider, P., and Scheckelhoff, D.  ASHP national survey of pharmacy practice in hospital settings:  monitoring and patient education --2003. American Journal of Health-System Pharmacy.  61(5):457-471, Mar. 1, 2004.

Hospital Nurse Staffing and Quality of Care.  Research in Action, Issue 14.  AHRQ Publication No. 04-0029.  Rockville, MD:  Agency for Healthcare Research and Quality, Mar. 2004.

Hoff, T., and others.  A review of the literature examining linkages between organizational factors, medical errors, and patient safety.  Medical Care Research and Review.  61(1):3-37, Mar. 2004.

2004 National patient safety goals adapted for programs.  Joint Commision Perspectives.  24(3):1, 3-5, Mar. 2004.

Croskerry, P., Shapiro, M., and Campbell, S.  Profiles in patient safety: medication errors in the emergency department. Academic Emergency Medicine.  11(3):289-29, Mar. 2004. 

Medication Safety Best Practices Guide for Ambulatory Care Use.  Brooklyn:  Creighton University Health Services Research Program, 2004.

Aspden, P., and others.  Patient Safety:  Achieving a New Standard for Care.  Washington, DC:  National Academies Press, 2004.  (WB 100 P298s 2004).

The Canadian Patient Safety Dictionary.  Sante, Canada:  Canadian Patient Safety Institute, Oct. 2003.

Pressure Ulcers in America:  Prevalence, Incidence, and Implications for the Future.  Reston, VA:  National Pressure Ulcer Advisory Panel, 2001.  (Ref WR 598 P935 2001).


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