A growing national chorus: The 2009 safe practices for better healthcare

Journal of Patient Safety

Volumn 4, Issue 4, 2008, Pages 253-260

  Denham, Charles R ^a,b  

^a Texas Medical Institute of Technology   (United States)

^b NONE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 67650154246     PISSN: 15498417     EISSN: 15498425     Source Type: Journal    
DOI: 10.1097/PTS.0b013e31818fbbb9     Document Type: Article

References (65)

1. Denham CR. May I have the envelope please? J Patient Saf. 2008;4(2):119-123.
2. Denham CR. From harmony to healing: join the quality choir. J Patient Saf. 2006;2(4):225-232.
3. Denham CR. The quality choir: from warm-up to harmony. JPatient Saf. 2005;1(3):170-175.
4. Denham CR. CEOs: meet your new revenue preservation officer.. .Your PSO! J Patient Saf. 2008;4(3):201-211.
5. National Quality Forum. Safe Practices for Better Healthcare: A Consensus Report. Washington, DC: The National Quality Forum; 2003.
6. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis ofpatient safety practices. Evid Rep Technol Assess (Summ). 2001;(43):i-668.
7. The Leapfrog Group. Factsheet. March 2008. Available at: http://www.leapfroggroup.org/media/file/ The-Leapfrog-Group-Fact-Sheet-03-2008. pdf. Accessed Sept. 24, 2008.
8. National Quality Forum. Safe Practices for Better Healthcare-2006 Update: A Consensus Report. Washington, DC: The National Quality Forum; 2007.
9. National Quality Forum. Safe Practices for Better Healthcare: 2009 Update. N.D. Available at: http://www.qualityforum.org/projects/ ongoing/safe-practices/. Accessed Sept. 24, 2008.
10. Agency for Healthcare Research and Quality. TeamSTEPPS Program. Available at: http://teamstepps.ahrq.gov/. Accessed September 27, 2008.
11. Lamb RM, Studdert DM, Bohmer RMJ, et al. Hospital disclosure practices: results of a national survey. Health Aff. 2003;22(2): 73-83.
12. McDonald T, Smith KM, Mayor D. In: Philibert Ingrid, ed. Full Disclosure and Residency Education. ACGME Bulletin. Chicago, IL; 2008.
13. Agency for Healthcare Research and Quality. Patient Safety Organizations. Legislation and Regulations: Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act): An Overview. Available at http://www.pso.ahrq.gov/ regulations/regulations.htm. Accessed September 8, 2008.
14. Public Law 109-41. July 29, 2005. Patient Safety and Quality Improvement Act of 2005. Available at http://www.pso.ahrq.gov/statute/ pl109-41.pdf. Accessed September 8, 2008.
15. Denham CR. TRUST: the five rights of the second victim. J Patient Saf. 2007;3(2):107-119
16. Hendrich A, Chow M, Skierczynski BA, et al. A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend TheirTime? The Permanente Journal 2008 Summer:12(3):25-34. Available at http:// xnet.kp.org/permanentejournal/ sum08/time-study.pdf. Accessed September 4, 2008.
17. Pronovost PJ. Physician staffing patterns. JAMA. 2002;288(17): 2151-2162.
18. Pronovost PJ. Interventions to reduce mortality among patients. J Crit Care. 2004;19(3):158-164.
19. Tate KE, Gardner RM, Weaver LK. A computerized laboratory alerting system. MD Comput. 1990;7:296-301.
20. Tate KE, Gardner RM. Computers, quality and the clinical laboratory: a look at critical value reporting. Proc 17th Annu Symp Comput App Med Care. 1993;193-197.
21. The Joint Commission. 2009 National Patient Safety Goals. Goal 2. Oakbrook Terrace, IL: The Joint Commission, 2009. Available at http://www.jointcommission.org/NR/ rdonlyres/F71BC4E9-FEB6-495C-99D8- DB9F0850E75B/0/ 09-NPSG-General-Presentation.ppt#265,4,The Sentinel Event Advisory Group. Accessed September 6, 2008.
22. Robert Wood Johnson Foundation. California pilot program creates Rx facts sheets, ads to inform consumers. 2004. Available at: http:// www.rwjf.org/reports/grr/041745.htm. Accessed on August 28, 2008.
23. Tarn D, Heritage J, Paterniti D, et al. Physician communication when prescribing new medications. Arch Intern Med. 2006;166: 1855-1862.
24. Aspden P, Wolcott J, Bootman JL, et al, eds. Preventing Medication Errors: Quality Chasm Series. Washington, DC: The National Academies Press; 2007.
25. The Joint Commission. 2009 National Patient Safety Goals. Presentation, n.d. Available at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/. Accessed Sept. 24, 2009.
26. K Klevens RM. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;22:160-166.
27. Centers for Disease Control. Guideline for hand hygiene in health-care settings. MMWR. 2002 ;51(RR-6):1-56.
28. The Joint Commission. Facts about the 2008 National Patient Safety Goals. Available at http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/08-npsg-facts.htm. Accessed August 23, 2008.
29. Smith N, Bresee J, Shay D, et al. Prevention and control of influenza. recommendations of the Advisory Committee on Immunization Practices (ACIP). CDC-MMWR 2006 June 28 (Early Release); 1-41.
30. Centers for Disease Control and Prevention. Influenza Vaccination of Health-Care Personnel. Available at http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5502a1.htm. Accessed August 23, 2008.
31. Centers for Disease Control and Prevention. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. Available at http:// www.cdc.gov/mmwr/preview/mmwrhtml/rr57e717a1. htm. Accessed August 23, 2008.
32. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.
33. Berenholtz SM, Pronovost PF, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014-2020.
34. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
35. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15.
36. Engelman R, Shahian D, Shemin R, et al. Workforce on evidence-based medicine, society of thoracic surgeons. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice. Ann Thorac Surg. 2007;83(4): 1569-1576.
37. Bratzler DW. The Surgical Infection Prevention and Surgical Care Improvement Projects: promises and pitfalls. Am Surg. 2006;72(11): 1010-1016; discussion 1021-30, 1133-48.
38. Clavet H, Hebert PC, Fergusson D, et al. Joint contracture following prolonged stay in the intensive care unit. CMAJ. 2008;178(6):691-697.
39. Paju S, Scannapieco PS. Oral biofilms, periodontitis, and pulmonary infections. Oral Dis. 2007;13(6):508-512.
40. IHI Improvement Report. No VAPs-It CAN Be Done! Available at http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Improvement Stories/NoVAPsItCanBeDone.htm. Accessed August 18, 2008.
41. Harrison PF, Lederberg J, eds. Antimicrobial Resistance: Issues and Options. Forum on Emerging Infections. Washington, DC: Institute of Medicine; 1998.
42. Shlaes DM, Gerding DN, John JF Jr, et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol. 1997;18(4):275-291.
43. Hidron AI, Edwards JR, Patel J, et al. Antimicrobial Resistant Pathogens Associated with Healthcare-Acquired Infections (HAIs) Reported to the CDC's National Healthcare Safety Network (NHSN), 2006-2007. SHEA 18th Annual Scientific Meeting, April 2008. Available at http://www.cdc.gov/ncidod/dhqp/ SHEA-Abstract1.html. Accessed September 3, 2008.
44. National Pressure Ulcer Advisory Panel. In: Cuddigan J, Ayello EA, Sussman C, eds. Pressure Ulcers in America: Prevalence, Incidence, and Implication for the Future. Reston, VA: NPUAP; 2001.
45. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-984.
46. Brandeis GH, Berlowitz DR, Katz P. Are pressure ulcers preventable? A survey of experts. Adv Skin Wound Care. 2001;14(5):244-248.
47. Heit JA, Cohen AT, Anderson FA Jr. Estimated annual number of incident and recurrent, non-fatal and fatal venous thromboembolism (VTE) events in the US. Blood. 2005;106(11):abstract #910:267a.
48. Tapson VF, Hyers TM, Waldo AL, et al. Antithrombotic therapy practices in US hospitals in an era of practice guidelines. Arch Intern Med. 2005;165:1458-1464.
49. Geerts WH, Clagett GP, Heit JA, et al. Prevention of venous Thromboembolism. Chest. 1995;108:312-334.
50. National Quality Forum. National Voluntary Consensus Standards for Prevention and Care ofVenous Thromboembolism: Additional Performance Measures: A Consensus Report. Washington, DC: National Quality Forum; 2008.
51. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention ofvenous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(suppl 6):381S-453S.
52. USP MedMarx Database, 2005. Available at http://www.usp.org/ products/medMarx/. Accessed August 27, 2008.
53. Kanal E, Barkovich AJ, Bell C, et al. ACR Guidance Document for Safe MR Practices:2007. AJR 2007;188:1-27. Available at http:// www.acr.org/ SecondaryMainMenuCategories/quality-safety/MRSafety/ safe-mr07.aspx. Accessed September 5, 2008.
54. Sadowski EA, Bennett LK, Chan MR, et al. Nephrogenic systemic fibrosis: risk factors and incidence estimation. Radiology. 2007;243:148-157.
55. Weigle JP, Broome DR. Nephrogenic systemic fibrosis: chronic imaging findings and review of the medical literature. Skeletal Radiol. 2008;37(5):457-464.
56. Organ Procurement and Transplantation Network. Available at http://www.optn.org/. Accessed June 27, 2008.
57. Department of Health and Human Services, Health Resources and Services Administration. 2005 National Survey of Organ and Tissue Donation Attitudes and Behaviors. Available at http://www.organ donor.gov/survey2005/introduction.shtm. Accessed August 25, 2008.
58. Shafer TJ, Wagner D, Chessare J, et al. US organ donation breakthrough collaborative increases organ donation. Crit Care Nurs Q. 2008;31(3):190-210.
59. ACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association Consensus statement on inpatient diabetes and glycemic control. Diabetes Care 2006 Aug;29(8):1955-62. Available at http://care.diabetesjournals.org/cgi/ content/extract/29/8/1955. Accessed September 9, 2008.
60. US Department of Veterans Affairs, National Center for Patient Safety. National Center for Patient Safety 2004 Falls Toolkit [online]. 2004. Available from URL: http://www.va.gov/ncps/SafetyTopics/fallstoolkit/ index.html. Accessed August 16, 2007.
61. Healey F, Monro A, Cockram A, et al. Using targeted risk factor reduction to prevent falls in older in-patients: a randomized controlled trial. Age Ageing. 2004;33:390-395.
62. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. 2006. Available at http://www.cdc.gov/ncipc/wisqars/. Accessed September 9, 2008.
63. Frush DP, Applegate K. Computed tomography and radiation: understanding the issues. JAm Coll Radiol. 2004;1:113 -119.
64. Brody AS, Frush DP, Huda W, et al. Radiation risk to children from computed tomography. Pediatrics. 2007;120:677-682.
65. The Chasing Zero Summit. Hospital-Acquired Infections. Available at: http://www.cardinalhealth.com/chasingzero/HAI/. Accessed September 27, 2008.