Advances in Patient Safety: New Directions and Alternative Approaches represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and other topics related to improving patient safety.
The 115 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. The volumes are organized around four broad themes: volume 1, assessment; volume 2, culture and redesign; volume 3, performance and tools; and volume 4, information technology and medication safety. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present tools and products that can be used to improve patient safety. This new publication complements AHRQ's Advances in Patient Safety: From Research to Implementation, published in 2005.
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Contents
Volume 1. Assessment
Volume 2. Culture and Redesign
Volume 3. Performance and Tools
Volume 4. Technology and Medication Safety
Volume 1. Assessment
Title Page
Citation Page
Preface. Carolyn Clancy
Acknowledgements
Table of Contents
Prologue to the Volume. Kerm Henriksen
Looking Forward, Benefitting from the Past
Envisioning Patient Safety in 2025: Eight Perspectives (PDF File, 83 KB)
Kerm Henriksen, et al.
What exactly is patient safety? (PDF File, 186 KB)
Linda Emanuel, et al.
Reporting Systems
Improving the Value of Patient Safety Reporting Systems. (PDF File, 82 KB)
Peter J. Provonost, et al.
The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (PDF File, 293 KB)
Katherine J. Jones, et al.
Proactive Post-Marketing Surveillance (PDF File, 124 KB)
Robert R. Campbell, et al.
The Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks within the Larger Framework of MedSun. (PDF File, 91 KB)
Donna Engleman, et al.
Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology. (PDF File, 109 KB)
Martin November, et al..
26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System. (PDF File, 484 KB)
Debora Simmons, et al..
Using An Anonymous Web-based Incident Reporting Tool to Embed the Principles of a High Reliability Organization. (PDF File, 97 KB)
Paul Conlon, et al.
Voluntary Adverse Event Reporting in Rural Hospitals. (PDF File, 120 KB)
Charles P. Schade, et al.
Improving error reporting in ambulatory pediatrics with team approach. (PDF File, 78 KB)
Daniel R. Neuspiel, et al..
Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative. (PDF File, 92 KB)
David R. West, et al..
Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act. (PDF File, 107 KB)
William Riley, et al..
Taxonomies and Measurement
Development of a Comprehensive Medical Error Ontology. (PDF File, 499 KB)
Pallavi Mokkarala, et al.
Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy. (PDF File, 132 KB)
John R. Clarke, et al.
A System to Describe and Reduce Medical Errors in Primary Care. (PDF File, 156 KB)
Victoria Kaprielian, et al.
Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard. (PDF File, 773 KB)
Carolyn E. Aydin, et al.
Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance. (PDF File, 226 KB)
Paul Hougland, et al.
Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium. (PDF File, 190 KB)
Hude Quan, et al.
Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration. (PDF File, 313 KB)
Stephenie L. Shimada, et al.
Challenges and Lessons Learned
Patient Safety Learning Pilot: Narratives from the Frontlines. (PDF File, 144 KB)
Shirley E Kellie, et al.
A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care. (PDF File, 1084 KB)
Ranjit Singh, et al.
Christiana Care Health System: Safety Mentor Program. (PDF File, 143 KB)
Michele Campbell, et al.
News Media and Health Care Providers at the Crossroads of Medical Adverse Events. (PDF File, 123 KB)
Pamela Whitten, et al.
Risk Assessment
Risk-Based Patient Safety Metrics. (PDF File, 164 KB)
Matthew C. Scanlon, et al.
Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning. (PDF File, 110 KB)
Donna M. Woods, et al.
A Model of Care Delivery to Reduce Falls in a Major Cancer Center. (PDF File, 100 KB)
Nancy E. Kline, et al.
Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care. (PDF File, 206 KB)
Mary L. Hook, et al.
Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings. (PDF File, 155 KB)
Robyn R.M. Gershon, et al.
Cause Analysis
The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures. (PDF File, 108 KB)
Lawrence L. Faltz, et al.
The Department of Veterans Affairs Emergency Airway Management Initiative. (PDF File, 104 KB)
Erik J. Stalhandske, et al.
Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities. (PDF File, 115 KB)
Patricia Ruddick, et al.
Common Cause Analysis: Focus on Institutional Change. (PDF File, 270 KB)
Anne Marie Browne, et al.
Peer Reviewers
Peer Reviewers - Volume 1. (PDF File, 17 KB)
Volume 2. Culture and Redesign
Title Page
Citation Page
Preface. Carolyn Clancy
Acknowledgements
Table of Contents
Prologue to the Volume. James Battles
Safety Culture and Organizational Issues
The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs. (PDF File, 327 KB)
Katherine J. Jones
Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture. (PDF File, 121 KB)
Karen L. Hannah, et al.
Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives. (PDF File, 223 KB)
Inga Adams-Pizarro, et al.
Measuring Safety Climate in Primary Care Offices. (PDF File, 268 KB)
Gurdev Singh, et al.
The PeaceHealth Ambulatory Medication Safety Culture Survey. (PDF File, 82 KB)
Ronald Stock, et al.
Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a
Regional Healthcare System Following the National Standard of Care. (PDF File, 295 KB)
Hardeek H. Shah, et al.
Is There an Association between Patient Safety Indicators and Hospital Teaching Status? (PDF File, 271 KB)
Peter E. Rivard, et al.
Organizational Behavior Management in Healthcare: Applications for Large-Scale Improvements in Patient Safety. (PDF File, 197 KB)
Thomas R. Cunningham, E. Scott Geller,
Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial. (PDF File, 154 KB)
Peter M. Layde, et al.
Clinical Process Improvement
Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World. (PDF File, 206 KB)
Stephen M. Borowitz, et al.
Documentation of Mandated Discharge Summary Components in Transitions from Acute to Sub-Acute Care. (PDF File, 98 KB)
Amy J. H. Kind, Maureen A. Smith
Challenges to Real-Time Decision Support in Healthcare. (PDF File, 301 KB)
Mark Fitzgerald, et al.
Risk reduction and systematic error management: standardization of the pediatric chemotherapy process. (PDF File, 302 KB)
Beverly Ann David, et al.
Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes From Paper to Electronic Systems. (PDF File, 119 KB)
Donald K. Baker, et al.
Promoting Best Practice and Safety through Preprinted Physician Orders. (PDF File, 200 KB)
George Ehringer, Barbara Duffy
The Impact of Standardized Order Sets on Quality and Financial Outcomes. (PDF File, 227 KB)
David J Ballard, et al.
Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility. (PDF File, 85 KB)
Kathy M. Harney, et al.
Creating safety in the testing process in primary care offices. (PDF File, 195 KB)
Nancy C. Elder, et al.
Role of the External Coach in Advancing Research Translation in Hospital-based Performance Improvement. (PDF File, 159 KB)
Nancy Donaldson, et al.
Strategies for Improving Patient Safety in Small Rural Hospitals. (PDF File, 116 KB)
Judith Tupper, et al.
Systems Redesign
Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. (PDF File, 91 KB)
Julie K. Johnson, et al.
Designing the Built Environment for the Culture and System of Patient Safety—A Conceptual, New Design Process. (PDF File, 171 KB)
Kenneth N. Dickerman, Paul Barach
Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption. (PDF File, 191 KB)
Heather Woodward Hagg, et al.
Transforming the Morbidity and Mortality Conference into an Instrument for System-wide Improvement. (PDF File, 74 KB)
Jamie N. Deis, et al.
Collaboratives and Patient Involvement
The Patient Safety Education Project: An International Collaboration. (PDF File, 128 KB)
Linda Emanuel, et al.
Harnessing the Potential of Healthcare Collaboratives: Lessons from the Keystone ICU Project. (PDF File, 117 KB)
Christine Goeschel, et al.
VHA’s National Falls Collaborative and Prevention Programs. (PDF File, 229 KB)
Erik Stalhandske, et al.
Hospital Language Services: Quality Improvement and Performance Measures. (PDF File, 128 KB)
Marsha Regenstein, et al.
Using Patient Complaints to Promote Patient Safety. (PDF File, 98 KB)
James W. Pichert, et al.
From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety. (PDF File, 244 KB)
Diane Valade, et al.
The Rural Physician Peer Review Model: A Virtual Solution. (PDF File, 99 KB)
Josie Williams, et al.
Peer Reviewers
Peer Reviewers - Volume 2. (PDF File, 17 KB)
Volume 3. Performance and Tools
Title Page
Citation Page
Preface. Carolyn Clancy
Acknowledgements
Table of Contents
Prologue to the Volume. Margaret Keyes
Teamwork and Communication
TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety. (PDF File, 417 KB)
Heidi B. King, et al.
Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement with Promising Teamwork Tools and Strategies. (PDF File, 249 KB)
John S. Webster, et al.
Building Self-Empowered Teams for Improving Safety in Post-operative Pain. (PDF File, 328 KB)
Ranjit Singh, et al.
Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At Risk Patients, Facilitates Proactive Interventions and Improves Outcomes. (PDF File, 221 KB)
Remi M. Hueckel, et al.
Improving Referral Communication Using a Referral Tool Within an Electronic Record. (PDF File, 157 KB)
Tejal K. Gandhi, et al.
Improving Patient Safety through Provider Communication Strategy Enhancements. (PDF File, 222 KB)
Catherine Dingley, et al.
Improving Clinical Communication and Patient Safety: Clinician Recommended Solutions. (PDF File, 145 KB)
Donna M. Woods, et al.
Simulation
In Situ Simulation: Challenges and Results. (PDF File, 145 KB)
Mary D. Patterson, et al.
The Nature, Characteristics and Patterns of Perinatal Critical Events Teams. (PDF File, 230 KB)
William Riley, et al.
Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding of Risks and Failures. (PDF File, 135 KB)
Stanley Davis, et al.
The Mobile Mock Operating Room: Bringing Team Training to the Point of Care. (PDF File, 1142 KB)
John T. Paige, et al.
Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training. (PDF File, 627 KB)
Ramnarayan Paragi Gururaja, et al.
Effect of recent refresher training on in situ simulated pediatric tracheal intubation psychomotor skill performance. (PDF File, 289 KB)
Akira Nishisaki, et al.
Simulation-Based Education Improves Patient Safety in Ambulatory Care. (PDF File, 173 KB)
Beth A. LaVelle, et al.
Human Factors
Pillars of a Smart, Safe Operating Room. (PDF File, 109 KB)
F. Jacob Seagull, et al.
High Hanging Fruit: Improving Transitions in Healthcare. (PDF File, 101 KB)
Shawna J. Perry, et al.
Minding the Gaps: Creating Resilience in Healthcare. (PDF File, 211 KB)
Christopher Nemeth, et al.
Error Producing Conditions in the Intensive Care Unit. (PDF File, 117 KB)
Frank A. Drews, et al.
Patient Monitors in Critical Care: Lessons for Improvement. (PDF File, 122 KB)
Frank A. Drews
Tools and Practices
Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The Re-Engineered Discharge (RED) Program. (PDF File, 151 KB)
Brian Jack, et al.
Creating an accurate medication list in the outpatient setting through a patient-centered approach. (PDF File, 135 KB)
Kathryn Kraft Leonhardt, et al.
The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems. (PDF File, 150 KB)
Gregg S. Meyer, et al.
Using Data Mining to Predict Errors in Chronic Disease Care. (PDF File, 264 KB)
Ryan M. McCabe, et al.
Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety. (PDF File, 134 KB)
Brenda K. Zierler, et al.
Using Process Measures to Improve Patient Safety Practices to Prevent Pulmonary Embolism. (PDF File, 178 KB)
Ellen Flink, et al.
A Tool to Assess Compliance in Anticoagulation Management. (PDF File, 122 KB)
Carla S. Huber, et al.
Using Lean Six Sigma Tools to Compare INR Measurements from Different Laboratories within a Community. (PDF File, 114 KB)
Brion Hurley, et al.
Using Six Sigma Methodology to Improve Handoff Communication in High Risk Patients. (PDF File, 249 KB)
Kshitij P. Mistry, et al.
10 Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma, and Team Training All Thrive in a Single Hospital? (PDF File, 138 KB)
Jon N. Meliones, et al.
Impact of Staff-Led Safety Walk Rounds. (PDF File, 82 KB)
Vicki L. Montgomery, et al.
Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet). (PDF File, 336 KB)
Niraj L. Sehgal, et al.
Peer Reviewers
Peer Reviewers - Volume 3. (PDF File, 17 KB)
Volume 4. Technology and Medication Safety
Title Page
Citation Page
Preface. Carolyn Clancy
Acknowledgements
Table of Contents
Prologue to the Volume. Mary Grady
Health Information Technology
“Safeware”: Safety-critical Computing and Healthcare Information Technology. (PDF File, 109 KB)
Robert L. Wears, et al.
Improving Perioperative Patient Safety. (PDF File, 97 KB)
Paul St. Jacques, and Michael Minear
The Impact of Health Information Technology on Work Process and Patient Care on Labor and Delivery. (PDF File, 255 KB)
Emily M. Campbell, et al.
Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine. (PDF File, 143 KB)
Stephenie Loux, et al.
Personal Health Records to Improve Health Information Exchange and Patient Safety. (PDF File, 493 KB)
James R. Fricton, Diane Davie
Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opiod Therapy for Chronic Pain Experience. (PDF File, 201 KB)
Martha Michel, et al.
Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences. (PDF File, 121 KB)
Emily B. Devine, et al.
Measuring IT Sophistication in Nursing Homes. (PDF File, 216 KB)
Gregory L. Alexander, et al.
The Potential of Hand-held Assistive Technology to Improve Safety for Elder Adults Aging in Place. (PDF File, 360 KB)
Shirley Ann Becker, Frank M. Webbe.
Efficiency Gains with Computerized Provider Order Entry. (PDF File, 77 KB)
Andrew M. Steele, et al.
Medication Safety
Clinical Pharmacists in Emergency Medicine. (PDF File, 117 KB)
Rollin J. Fairbanks, et al.
Intravenous Infusion Safety Initiative: Collaboration, Evidence-based Best Practices and “Smart” Technology Help Avert High-risk Adverse Drug Events and Improve Patient Outcomes. (PDF File, 165 KB)
Ray Maddox, et al.
Continuous Respiratory Monitoring and “Smart” Infusion System Improve Safety of Patient-Controlled Anesthesia in the Postoperative Period. (PDF File, 371 KB)
Ray R. Maddox, et al.
Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study methods. (PDF File, 308 KB)
Andrew L. Masica, et al.
Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study. (PDF File, 117 KB)
John Lynch, et al.
Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes. (PDF File, 75 KB)
Karla Miller, et al.
Imbedding Research in Practice to Improve Medication Safety. (PDF File, 182 KB)
Marsha A. Raebel, et al.
Risk of Concurrent Use of Prescription Drugs with Herbal and Dietary Supplements in Ambulatory Care. (PDF File, 177 KB)
Robert E. Graham, et al.
Using Home Visits to Understand Medication Errors in Children. (PDF File, 207 KB)
Kathleen E. Walsh, et al.
Developing a Community-Wide Electronic Shared Medication List. (PDF File, 183 KB)
Ron Stock, et al.
Peer Reviewers
Peer Reviewers - Volume 4. (PDF File, 17 KB)
AHRQ Publication No. 08-0034-1 (Vol. 1)
AHRQ Publication No. 08-0034-2 (Vol. 2)
AHRQ Publication No. 08-0034-3 (Vol. 3)
AHRQ Publication No. 08-0034-4 (Vol. 4)
Current as of July 2008
Internet Citation:
Advances in Patient Safety: New Directions and Alternative Approaches. Volumes 1-4, AHRQ Publication Nos. 08-0034 (1-4). July 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/advances2/
540 Gaither Road Rockville, MD 20850