-
4
-
-
34548328183
-
State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives. Portland, ME: National Academy for State
-
Rosenthal J., Booth M, Flowers L, Riley T. Current State Programs Addressing Medical Errors: An Analysis of Mandatory Reporting and Other Initiatives. Portland, ME: National Academy for State Health Policy ; 2001.
-
(2001)
Health Policy
-
-
Rosenthal, J.1
-
5
-
-
34548340625
-
Maximizing the Use of State Adverse Event Data to Improve Patient Safety. Portland, ME: National Academy for State
-
Rosenthal J., Booth M. Maximizing the Use of State Adverse Event Data to Improve Patient Safety. Portland, ME: National Academy for State Health Policy ; 2005.
-
(2005)
Health Policy
-
-
Rosenthal, J.1
Booth, M.2
-
6
-
-
34548352787
-
-
Washington, DC: Medicare Payment Advisory Commission;
-
Medicare Payment Advisory Commission (MEDPAC). Report to the Congress: New Approaches in Medicare. Washington, DC: Medicare Payment Advisory Commission ; 2004: 147.
-
(2004)
Report to the Congress: New Approaches in Medicare
, pp. 147
-
-
-
8
-
-
34548342841
-
HealthGrades Quality Study: Second Annual Patient Safety in American Hospitals Report
-
Golden, CO: Grades;
-
HealthGrades Quality Study: Second Annual Patient Safety in American Hospitals Report. Golden, CO: Health Grades ; 2005.
-
(2005)
Health
-
-
-
9
-
-
33646797002
-
Patient safety and quality improvement act of 2005
-
Fassett WE Patient safety and quality improvement act of 2005. Ann Pharmacother. 2006 ; 40: 917-924.
-
(2006)
Ann Pharmacother.
, vol.40
, pp. 917-924
-
-
Fassett, W.E.1
-
10
-
-
0034681819
-
Human error: Models and management
-
Reason J. Human error: models and management. Br Med J. 2000 ; 320: 768-770.
-
(2000)
Br Med J.
, vol.320
, pp. 768-770
-
-
Reason, J.1
-
13
-
-
0032752082
-
Organizing to reduce the vulnerabilities of complexity
-
Perrow C. Organizing to reduce the vulnerabilities of complexity. J Contingencies Crisis Manage. 1999 ; 7: 150-155.
-
(1999)
J Contingencies Crisis Manage.
, vol.7
, pp. 150-155
-
-
Perrow, C.1
-
17
-
-
0035885159
-
Complexity science: The challenge of complexity in health care
-
Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. Br Med J. 2001 ; 323: 625-628.
-
(2001)
Br Med J.
, vol.323
, pp. 625-628
-
-
Plsek, P.E.1
Greenhalgh, T.2
-
18
-
-
0035934650
-
Complexity and clinical care [erratum in: BMJ. 2001;323:993]
-
Wilson T., Holt T., Greenhalgh T. Complexity and clinical care [erratum in: BMJ. 2001;323:993]. Br Med J. 2001 ; 323: 685-688.
-
(2001)
Br Med J.
, vol.323
, pp. 685-688
-
-
Wilson, T.1
Holt, T.2
Greenhalgh, T.3
-
19
-
-
0035968621
-
Complexity, leadership, and management in healthcare organisations
-
Plsek P., Wilson T. Complexity, leadership, and management in healthcare organisations. Br Med J. 2001 ; 323: 746-749.
-
(2001)
Br Med J.
, vol.323
, pp. 746-749
-
-
Plsek, P.1
Wilson, T.2
-
20
-
-
0035818380
-
Coping with complexity: Educating for capability
-
Fraser SW, Greenhalgh T. Coping with complexity: educating for capability. Br Med J. 2001 ; 323: 799-803.
-
(2001)
Br Med J.
, vol.323
, pp. 799-803
-
-
Fraser, S.W.1
Greenhalgh, T.2
-
21
-
-
12444267092
-
Patient safety as an organizational systems issue: Lessons from a variety of industries
-
Youngberg BJ, Hatlie MJ, eds. Sudbury, MA: Jones & Bartlett ;
-
Roberts KH, Yu K., Van Stralen D. Patient safety as an organizational systems issue: lessons from a variety of industries. In: Youngberg BJ, Hatlie MJ, eds. The Patient Safety Handbook. Sudbury, MA: Jones & Bartlett ; 2004: 169-186.
-
(2004)
The Patient Safety Handbook
, pp. 169-186
-
-
Roberts, K.H.1
Yu, K.2
Van Stralen, D.3
-
23
-
-
6344229692
-
The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf
-
Leonard M., Graham S., Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 ; 13 (suppl 1). 85-90.
-
(2004)
Health Care
, vol.13
, Issue.1
, pp. 85-90
-
-
Leonard, M.1
Graham, S.2
Bonacum, D.3
-
24
-
-
33748693969
-
SBAR: A shared mental model for improving communication between clinicians
-
Haig KM, Sutton S., Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006 ; 32: 167-175.
-
(2006)
Jt Comm J Qual Patient Saf
, vol.32
, pp. 167-175
-
-
Haig, K.M.1
Sutton, S.2
Whittington, J.3
-
26
-
-
33644857159
-
Forum 30 safe practices: Priority and progress in Iowa hospitals
-
Ward MM, Evans TC, Spies AJ, et al. National Quality Forum 30 safe practices: priority and progress in Iowa hospitals. Am J Med Qual. 2006 ; 21: 101-108.
-
(2006)
Am J Med Qual.
, vol.21
, pp. 101-108
-
-
Ward, M.M.1
Evans, T.C.2
Spies, A.J.3
Quality, N.4
-
27
-
-
0037164054
-
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction
-
Aiken LH, Clarke SP, Sloane DM, Sochalski J., Silber JH Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002 ; 288: 1987-1993.
-
(2002)
JAMA.
, vol.288
, pp. 1987-1993
-
-
Aiken, L.H.1
Clarke, S.P.2
Sloane, D.M.3
Sochalski, J.4
Silber, J.H.5
-
28
-
-
3242707986
-
The working hours of hospital staff nurses and patient safety
-
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004 ; 23: 202-212.
-
(2004)
Health Aff (Millwood)
, vol.23
, pp. 202-212
-
-
Rogers, A.E.1
Hwang, W.T.2
Scott, L.D.3
Aiken, L.H.4
Dinges, D.F.5
-
29
-
-
32044463181
-
Nurse staffing in hospitals: Is there a business case for quality?
-
Needleman J., Buerhaus PI, Stewart M., et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff (Millwood). 2006 ; 25: 204-211.
-
(2006)
Health Aff (Millwood)
, vol.25
, pp. 204-211
-
-
Needleman, J.1
Buerhaus, P.I.2
Stewart, M.3
-
30
-
-
0037663736
-
Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review
-
Kaushal R., Shojania KG, Bates DW Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003 ; 163: 1409-1416.
-
(2003)
Arch Intern Med.
, vol.163
, pp. 1409-1416
-
-
Kaushal, R.1
Shojania, K.G.2
Bates, D.W.3
-
31
-
-
0038482036
-
Computer physician order entry: Benefits, costs, and issues
-
Kuperman GJ, Gibson RF Computer physician order entry: benefits, costs, and issues. Ann Intern Med. 2003 ; 139: 31-39.
-
(2003)
Ann Intern Med.
, vol.139
, pp. 31-39
-
-
Kuperman, G.J.1
Gibson, R.F.2
-
32
-
-
33646121208
-
Return on investment for a computerized physician order entry system
-
Kaushal R., Jha AK, Franz C., et al. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006 ; 13: 261-266.
-
(2006)
J Am Med Inform Assoc
, vol.13
, pp. 261-266
-
-
Kaushal, R.1
Jha, A.K.2
Franz, C.3
-
33
-
-
0035038552
-
Outpatient laparoscopic cholecystectomy: Patient outcomes after implementation of a clinical pathway
-
Calland JF, Tanaka K., Foley E., et al. Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway. Ann Surg. 2001 ; 233: 704-715.
-
(2001)
Ann Surg.
, vol.233
, pp. 704-715
-
-
Calland, J.F.1
Tanaka, K.2
Foley, E.3
-
34
-
-
0037351660
-
Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection
-
Stephen AE, Berger DL Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003 ; 133: 277-282.
-
(2003)
Surgery
, vol.133
, pp. 277-282
-
-
Stephen, A.E.1
Berger, D.L.2
-
35
-
-
85009661516
-
Quality improvement and proactive hazard analysis models: Deciphering a new Tower of Babel
-
Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Washington, DC: National Academies Press;
-
McDonough JE, Solomon R., Petosa L. Quality improvement and proactive hazard analysis models: deciphering a new Tower of Babel. In: Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard of Care. Washington, DC: National Academies Press ; 2004: 471-508.
-
(2004)
Patient Safety: Achieving A New Standard of Care
, pp. 471-508
-
-
McDonough, J.E.1
Solomon, R.2
Petosa, L.3
-
36
-
-
0041814984
-
Proactive Hazard Analysis and Health Care Policy
-
New York:
-
McDonough JE Proactive Hazard Analysis and Health Care Policy. New York: Milbank Memorial Fund ; 2002.
-
(2002)
Milbank Memorial Fund
-
-
McDonough, J.E.1
-
37
-
-
0035486819
-
Developing and deploying a patient safety program in a large health care delivery system: You can't fix what you don't know about
-
Bagian JP, Lee C., Gosbee J., et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv. 2001 ; 27: 522-532.
-
(2001)
Jt Comm J Qual Improv
, vol.27
, pp. 522-532
-
-
Bagian, J.P.1
Lee, C.2
Gosbee, J.3
-
39
-
-
28944453114
-
Mandatory state-based error-reporting systems: Current and future prospects
-
Wood KE, Nash DB Mandatory state-based error-reporting systems: current and future prospects. Am J Med Qual. 2005 ; 20: 297-303.
-
(2005)
Am J Med Qual.
, vol.20
, pp. 297-303
-
-
Wood, K.E.1
Nash, D.B.2
-
42
-
-
33845452417
-
Translating patient safety legislation into health care practice
-
Rabinowitz Abk, Clarke, JR, Marella W., et al. Translating patient safety legislation into health care practice. Jt Comm J Qual Patient Saf. 2006 ; 32: 676-681.
-
(2006)
Jt Comm J Qual Patient Saf.
, vol.32
, pp. 676-681
-
-
Abk, R.1
Clarke, J.R.2
Marella, W.3
-
43
-
-
34548346789
-
Case study: NASA/VA patient safety reporting system
-
2006
-
McCarthy D. Case study: NASA/VA patient safety reporting system. Commonwealth Fund Quality Matters Newsletter, 2004. Available at: http://www.cmwf.org/publications/publications_show.htm?doc_id=245255. Accessed August 14, 2006.
-
(2004)
Commonwealth Fund Quality Matters Newsletter
-
-
McCarthy, D.1
-
44
-
-
0033814423
-
Human error in hospitals and industrial accidents: Current concepts
-
Spencer FC Human error in hospitals and industrial accidents: current concepts. J Am Coll Surg. 2000 ; 191: 410-418.
-
(2000)
J Am Coll Surg.
, vol.191
, pp. 410-418
-
-
Spencer, F.C.1
-
45
-
-
3843110096
-
Communicating with patients about medical errors: A review of the literature
-
Mazor KM, Simon SR, Gurwitz JH Communicating with patients about medical errors: a review of the literature. Arch Intern Med. 2004 ; 164: 1690-1697.
-
(2004)
Arch Intern Med.
, vol.164
, pp. 1690-1697
-
-
Mazor, K.M.1
Simon, S.R.2
Gurwitz, J.H.3
-
46
-
-
0036884176
-
Eisenberg Patient Safety Awards: Advocacy: the Lexington Veterans Affairs Medical Center
-
Kraman SS, Cranfill L., Hamm G., Woodard T., John M. Eisenberg Patient Safety Awards: Advocacy: the Lexington Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002 ; 28: 646-650.
-
(2002)
Jt Comm J Qual Improv.
, vol.28
, pp. 646-650
-
-
Kraman, S.S.1
Cranfill, L.2
Hamm, G.3
Woodard, T.4
John, M.5
-
47
-
-
33644678974
-
Patient preferences for error disclosure, reporting, and legal action after medical error in the care of their children
-
Hobgood C., Tamayo-Sarver JH, Elms A., Weiner B. Patient preferences for error disclosure, reporting, and legal action after medical error in the care of their children. Pediatrics. 2005 ; 116: 1276-1286.
-
(2005)
Pediatrics
, vol.116
, pp. 1276-1286
-
-
Hobgood, C.1
Tamayo-Sarver, J.H.2
Elms, A.3
Weiner, B.4
-
48
-
-
1542328163
-
Health plan members' views about disclosure of medical errors
-
Mazor KM, Simon SR, Yood RA, et al. Health plan members' views about disclosure of medical errors. Ann Intern Med. 2004 ; 140: 409-418.
-
(2004)
Ann Intern Med.
, vol.140
, pp. 409-418
-
-
Mazor, K.M.1
Simon, S.R.2
Yood, R.A.3
-
49
-
-
34548368477
-
Curing the malpractice crisis
-
Boothman RC Curing the malpractice crisis. Surgical News. Aug 2006 ; 12.
-
(2006)
Surgical News
, vol.12
-
-
Boothman, R.C.1
-
53
-
-
0004001942
-
-
National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP taxonomy of medical errors, 1998. Available at: http://www.nccmerp.org/pdf/tax02001-07-31.pdf. Accessed April 23, 2007.
-
(2007)
NCC MERP Taxonomy of Medical Errors, 1998
-
-
-
58
-
-
0031767967
-
Identification and classification of the causes of events in transfusion medicine
-
Kaplan HS, Battles JB, Van der Schaaf TW, et al. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998 ; 38: 1071-1081.
-
(1998)
Transfusion.
, vol.38
, pp. 1071-1081
-
-
Kaplan, H.S.1
Battles, J.B.2
Van Der Schaaf, T.W.3
-
59
-
-
34547503984
-
How a system for reporting medical errors can and cannot improve patient safety
-
Clarke JR How a system for reporting medical errors can and cannot improve patient safety. Am Surg. 2006: 72: 1088-1091.
-
(2006)
Am Surg.
, vol.72
, pp. 1088-1091
-
-
Clarke, J.R.1
-
60
-
-
34548342840
-
-
Pennsylvania Patient Safety Reporting System (PA-PSRS) Patient Safety Advisories. Available at: http://www.psa.state.pa.us/psa/cwp/view.asp?a= 1293&q=447107&psaNav=|. Accessed August 14, 2006.
-
(2006)
Patient Safety Advisories
-
-
-
61
-
-
34548370612
-
-
New Jersey Department of Health and Senior Services Patient Safety Initiatives. Available at: http://www.state.nj.us/health/hcqo/ps/newsletter. shtml. Accessed August 14, 2006.
-
(2006)
-
-
-
62
-
-
28844491799
-
Health care provider use of private sector internal error-reporting systems
-
Roumm AR, Sciamanna CN, Nash DB Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005 ; 20: 304-312.
-
(2005)
Am J Med Qual.
, vol.20
, pp. 304-312
-
-
Roumm, A.R.1
Sciamanna, C.N.2
Nash, D.B.3
-
63
-
-
28944433025
-
The long road to patient safety: A status report on patient safety systems
-
Longo DR, Hewett JE, Ge B., Schubert S. The long road to patient safety: a status report on patient safety systems. JAMA. 2005 ; 294: 2858-2865.
-
(2005)
JAMA.
, vol.294
, pp. 2858-2865
-
-
Longo, D.R.1
Hewett, J.E.2
Ge, B.3
Schubert, S.4
-
65
-
-
0348216532
-
Safety culture assessment: A tool for improving patient safety in healthcare organizations. Quality Saf
-
Nieva VF, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Quality Saf Health Care. 2003 ; 12 (suppl 2). 17-23.
-
(2003)
Health Care
, vol.12
, Issue.2
, pp. 17-23
-
-
Nieva, V.F.1
Sorra, J.2
-
66
-
-
33745611771
-
How will we know patients are safer? An organization-wide approach to measuring and improving safety
-
Pronovost P., Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med. 2006 ; 34: 1988-1995.
-
(2006)
Crit Care Med.
, vol.34
, pp. 1988-1995
-
-
Pronovost, P.1
Holzmueller, C.G.2
Needham, D.M.3
-
68
-
-
84996605942
-
Boss buy-in: One of the least expensive tools to enhance safety
-
Dickey NW Boss buy-in: one of the least expensive tools to enhance safety. J Patient Saf. 2005 ; 1: 123.
-
(2005)
J Patient Saf.
, vol.1
, pp. 123
-
-
Dickey, N.W.1
-
69
-
-
33748333207
-
Engagement of leadership in quality improvement initiatives: Executive quality improvement survey results
-
Vaughn T., Koepke M., Kroch E., et al. Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. J Patient Saf. 2006 ; 2: 2-9.
-
(2006)
J Patient Saf.
, vol.2
, pp. 2-9
-
-
Vaughn, T.1
Koepke, M.2
Kroch, E.3
-
70
-
-
34548352786
-
Self-assessment questionnaire 30: Patient safety
-
Plymouth Meeting, PA: ECRI;
-
ECRI Institute. Self-assessment questionnaire 30: patient safety. In: Healthcare Risk Control. Vol 1. Plymouth Meeting, PA: ECRI ; 2005: 1-13.
-
(2005)
Healthcare Risk Control
, pp. 1-13
-
-
Institute, E.1
-
71
-
-
33748121064
-
Getting the board on board: Engaging hospital boards in quality and patient safety
-
Joshi MS, Hines SC Getting the board on board: engaging hospital boards in quality and patient safety. Jt Comm J Qual Patient Saf. 2006 ; 32: 179-187.
-
(2006)
Jt Comm J Qual Patient Saf.
, vol.32
, pp. 179-187
-
-
Joshi, M.S.1
Hines, S.C.2
-
72
-
-
33745818567
-
Size, composition, and culture of high-performing hospital boards
-
Prybil LD Size, composition, and culture of high-performing hospital boards. Am J Med Qual. 2006 ; 21: 224-229.
-
(2006)
Am J Med Qual.
, vol.21
, pp. 224-229
-
-
Prybil, L.D.1
-
73
-
-
33646078911
-
Norms Group. Enhancing the use of clinical guidelines: A social norms perspective
-
McDonnell Norms Group. Enhancing the use of clinical guidelines: a social norms perspective. J Am Coll Surg. 2006 ; 202: 826-836.
-
(2006)
J Am Coll Surg.
, vol.202
, pp. 826-836
-
-
McDonnell1
|