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How will we know patients are safer? An organization-wide approach to measuring and improving safety
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This review provides a conceptual model for monitoring patient safety at the hospital level using a safety scorecard, and a detailed description of a tool to help organizations learn from defects
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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. This review provides a conceptual model for monitoring patient safety at the hospital level using a safety scorecard, and a detailed description of a tool to help organizations learn from defects.
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Aspden P, Corrigan JM, Wolcott J, Erickson SM, editors. Institute of Medicine: Patient safety: achieving a new standard for care. Washington, DC: National Academy Press; 2004.
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Institute of Medicine: Patient safety: achieving a new standard for care
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Patient safety event reporting in critical care: A study of three intensive care units
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This study demonstrates how an internally designed, card-reporting program can improve reporting of medical errors and adverse events
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Harris CB, Krauss MJ, Coopersmith CM, et al. Patient safety event reporting in critical care: a study of three intensive care units. Crit Care Med 2007; 35:1068-1076. This study demonstrates how an internally designed, card-reporting program can improve reporting of medical errors and adverse events.
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Harris, C.B.1
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Comparing ICU populations: Background and current methods
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Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia
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Martinez EA, Kim LJ, Faraday N, et al. Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia. Crit Care Med 2003; 31:2302-2308.
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Eliminating catheter-related bloodstream infections in the intensive care unit
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Pronovost PJ, Needham D, Berenholtz SM, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-2732. This paper reports a multifaceted intervention in over 100 Michigan ICUs that resulted in a large and sustained reduction in CRBSI rates by up to 66% with a median infection rate of 0 throughout the entire 18-month postintervention study period.
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Pronovost PJ, Needham D, Berenholtz SM, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-2732. This paper reports a multifaceted intervention in over 100 Michigan ICUs that resulted in a large and sustained reduction in CRBSI rates by up to 66% with a median infection rate of 0 throughout the entire 18-month postintervention study period.
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A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group
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Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia
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Resar R, Pronovost P, Haraden C, et al. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005; 31:243-248.
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A web-based tool for the Comprehensive Unit-Based Safety Program (CUSP)
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This article describes a six-step Comprehensive Unit-Based Safety Program (CUSP) designed to improve culture and safety. Case studies are provided
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Pronovost PJ, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-Based Safety Program (CUSP). Jt Comm J Qual Patient Saf 2006; 32:119-129. This article describes a six-step Comprehensive Unit-Based Safety Program (CUSP) designed to improve culture and safety. Case studies are provided.
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Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006; 32:102-108. This tutorial describes the Learning from Defects (LFD) tool; a structured approach to help caregivers and administrators identify systems that contribute to defects; it includes a framework to evaluate the impact of interventions to improve patient safety.
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Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006; 32:102-108. This tutorial describes the Learning from Defects (LFD) tool; a structured approach to help caregivers and administrators identify systems that contribute to defects; it includes a framework to evaluate the impact of interventions to improve patient safety.
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Creating the web-based intensive care unit safety reporting system
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A system factors analysis of 'line, tube, and drain' incidents in the intensive care unit
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Needham DM, Sinopoli DJ, Thompson DA, et al. A system factors analysis of 'line, tube, and drain' incidents in the intensive care unit. Crit Care Med 2005; 33:1701-1707.
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Measurement: Assessing a safety culture
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Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in healthcare organizations. Health Serv Res 2006; 41 (4 Pt 2):1599-1617. This paper describes a comprehensive approach to help healthcare organizations reliably deliver effective interventions. The five-step model incorporates strategies to improve safety culture; target senior leaders, team leaders, and front-line staff; and facilitate change management - engage, educate, execute, and evaluate - for planned interventions.
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Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in healthcare organizations. Health Serv Res 2006; 41 (4 Pt 2):1599-1617. This paper describes a comprehensive approach to help healthcare organizations reliably deliver effective interventions. The five-step model incorporates strategies to improve safety culture; target senior leaders, team leaders, and front-line staff; and facilitate change management - engage, educate, execute, and evaluate - for planned interventions.
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