Advances in Patient Safety: From Research to Implementation

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last 5 years. This compendium is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs.

The 140 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. 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 useful tools and products that can be used to improve patient safety.

For print versions of articles, download the PDF files.

Note: PDF files can be accessed using the Adobe® Reader. Go to Plugin Software Help.

 Contents

Acknowledgments
Preface

Volume 1. Research Findings

Prologue: Five Years Later—Are We Any Safer? (  PDF File, 121 KB)
   Brent C. James

The Clinical Environment

Can We Talk? Priorities for Patient Care Differed Among Health Care Providers ( PDF File, 155 KB)
      Bradley Evanoff, Patricia Potter, Laurie Wolf, Deborah Grayson, Clay Dunagan, Stuart Boxerman
Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians ( PDF File, 208 KB)
      Timothy J. Hoff, Henry Pohl, Joel Bartfield
An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors ( PDF File, 318 KB)
      Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff
Do Transient Working Conditions Trigger Medical Errors? ( PDF File, 172 KB)
      Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff
Organizational Climate, Stress, and Error in Primary Care: The MEMO Study ( PDF File, 187 KB)
      Mark Linzer, Linda Baier Manwell, Marlon Mundt, Eric Williams, Ann Maguire, Julia McMurray, Mary Beth Plane
Seamless Care: Safe Patient Transitions from Hospital to Home ( PDF File, 230 KB)
      Andrea M. Spehar, Robert R. Campbell, Carron Cherrie, Polly Palacios, Donna Scott, Jacquelyn L. Baker, Brad Bjornstad, Jay Wolfson

Medication Safety

Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician's Office ( PDF File, 376 KB)
      Kimberly A. Galt, Ann M. Rule, Bartholomew E. Clark, James D. Bramble, Wendy Taylor, Kevin G. Moores
Quantitative and Qualitative Analysis of Medication Errors: The New York Experience ( PDF File, 217 KB)
      Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink, Ruth Leslie
Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System ( PDF File, 287 KB)
      Radhika Desikan, Melissa J. Krauss, W. Claiborne Dunagan, Erin Christensen Rachmiel, Thomas Bailey, Victoria J. Fraser
Prescribing Safety in Ambulatory Care: Physician Perspectives ( PDF File, 183 KB)
      Thomas G. Rundall, John Hsu, Jennifer Elston Lafata, Vicki Fung, Kathryn A. Paez, Jan Simpkins, Steven R. Simon, Scott B. Robinson,
      Connie Uratsu, Margaret J. Gunter, Stephen B. Soumerai, Joseph V. Selby
Impact of Pharmacy-led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients ( PDF File, 174 KB)
      Joseph G. Weaver, Judy Enders McManus, Tammy Leung, Rhonda B. Mangione, Heidi R. Snow, Stacie K. Hackworth
Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs ( PDF File, 172 KB)
      Dustin D. French, Andrea M. Spehar, Robert R. Campbell, Polly Palacios, Roy W. Coakley, Nicholas Coblio, Heidi Means, Dennis C. Werner,  David M. Angaran
Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance ( PDF File, 254 KB)
      Dean Schillinger, Eddie Machtinger, Frances Wang, Maytrella Rodriguez, Andrew Bindman
A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics ( PDF File, 260 KB)
      Valerie J. Reige

Surveillance

Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications ( PDF File, 268 KB)
      Carol J. Masheter, Paul Hougland, Wu Xu
Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes ( PDF File, 185 KB)
      Mark Van Tuinen, Susan Elder, Carolyn Link, Susan Li, John H. Song, Tracey Pritchett
Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations ( PDF File, 194 KB)
      Robert R. Campbell, Douglas D. Bradham, Aurora Sanchez-Anguiano, Dennis H. Werner, Andrea M. Spehar, Dustin French, Polly Palacios
A Study of Adverse Occurrences and Major Functional Impairment Following Surgery ( PDF File, 185 KB)
      Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances
Measuring Safety: A New Perspective on Outcomes of a Long-term Intensive Case Management Program ( PDF File, 476 KB)
      Rosa M. Cotayo, Holly A. Grems, Elizabeth Sloan
The Impact of a Patient Safety Program on Medical Error Reporting ( PDF File, 177 KB)
      Donald R. Woolever

Technology

Making Information Technology a Team Player in Safety: The Case of Infusion Devices ( PDF File, 430 KB)
      Christopher Nemeth, Mark Nunnally, Michael O'Connor, P. Allan Klock, Richard Cook
Post-fielding Surveillance of a Guideline-based Decision Support System ( PDF File, 232 KB)
      Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B. Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu,
      Mark A. Musen, Brian B. Hoffman, Mary K. Goldstein
The Role of Patient Safety in the Device Purchasing Process ( PDF File, 140 KB)
      Todd R. Johnson, Jiajie Zhang, Vimla L. Patel, Alla Keselman, Xiaozhou Tang, Juliana J. Brixey, Danielle Paige, James P. Turley

Ambulatory and Rural

Learning from Errors in Ambulatory Pediatrics ( PDF File, 186 KB)
      Julie J. Mohr, Carole M. Lannon, Kathleen A. Thoma, Donna Woods, Eric J. Slora, Richard C. Wasserman, Lynne Uhring
Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care ( PDF File, 204 KB)
      Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush
From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings ( PDF File, 135 KB)
      Ann Freeman Cook, Helena Hoas, Katarina Guttmannova
Comparing Patient Safety in Rural Hospitals by Bed Count ( PDF File, 184 KB)
      Stephenie L. Loux, Susan M. C. Payne, Astrid Knott

Policy and Medical Expenditures

Regulation of Health Policy: Patient Safety and the States ( PDF File, 186 KB)
      Joanna Weinberg, Lee H. Hilborne, Quang-Tuyen Nguyen
What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare ( PDF File, 242 KB)
      William E. Encinosa, Fred J. Hellinger
Financial and Demographic Influences on Medicare Patient Safety Events ( PDF File, 194 KB)
      Didem Bernard, William E. Encinosa

Peer Reviewers—Volume 1

Volume 2. Concepts and Methodology

Prologue: Systems Thinking and Patient Safety ( PDF File, 105 KB)
      Paul M. Schyve

Measurement and Taxonomies

Applying Patient Safety Indicators (PSIs) Across Health Care Systems: Achieving Data Comparability ( PDF File, 218 KB)
      Peter E. Rivard, A. Rani Elwy, Susan Loveland, Shibei Zhao, Dennis Tsilimingras, Anne Elixhauser, Patrick S. Romano, Amy K. Rosen
Validation of AHRQ's Patient Safety Indicator for Accidental Puncture or Laceration ( PDF File, 186 KB)
      Brian Gallagher, Liyi Cen, Edward L. Hannan
Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator ( PDF File, 197 KB)
      Brian Gallagher, Liyi Cen, Edward L. Hannan
Patient Safety Research in Medical Group Practices: Measurement and Data Challenges ( PDF File, 174 KB)
      Amy R. Wilson, Bryan E. Dowd, John E. Kralewski
Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative ( PDF File, 186 KB)
      Wilson D. Pace, Douglas H. Fernald, Daniel M. Harris, L. Miriam Dickinson, Rodrigo Araya-Guerra, Elizabeth W. Staton, Rebecca VanVorst, Bennett L. Parnes, Deborah S. Main
Taxonomic Guidance for Remedial Actions ( PDF File, 362 KB)
      Bruce Thomadsen, Shi-Woei Lin
The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization ( PDF File, 277 KB)
      Katrin S. Kohl, Jan Bonhoeffer, M. Miles Braun, Robert T. Chen, Philippe Duclos, Harald Heijbel, Ulrich Heininger, Elisabeth Loupi, S. Michael Marcy, the Brighton Collaboration

Surveillance

Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency ( PDF File, 185 KB)
      David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder, Lisa J. Jaser, Nancy Safer, Paul Davern
Medical Injury Identification Using Hospital Discharge Data ( PDF File, 196 KB)
      Peter M. Layde, Linda N. Meurer, Clare Guse, John R. Meurer, Hongyan Yang, Prakash Laud, Evelyn M. Kuhn, Karen J. Brasel, Stephen W. Hargarten
Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative ( PDF File, 239 KB)
      Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Marr, Javán Quintela, Deborah S. Main
Development and Implementation of the University of Texas Close Call Reporting System ( PDF File, 187 KB)
      Sharon K. Martin, Jason M. Etchegaray, Debora Simmons, W. Thomas Belt, Kelly Clark

Medication Safety

Translating Patient Safety Research into Clinical Practice ( PDF File, 189 KB)
      David J. Magid, Paul A. Estabrooks, David W. Brand, Marsha A. Raebel, Ted E. Palen, John F. Steiner, Eli J. Korner, David W. Bates, Richard Platt, Russell E. Glasgow
Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting ( PDF File, 164 KB)
      Andrew C. Seger, Tejal K. Gandhi, Carol Hope, J. Marc Overhage, Michael D. Murray, David Weber, Julie Fiskio, Evgenia Teal, David W. Bates
Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors  (PDF File, 188 KB)
      Emily Beth Devine, Jennifer L. Wilson-Norton, Nathan M. Lawless, Thomas K. Hazlet, Ryan Hansen, Kerry Kelly, Stephanie Te, Carolyn Wong
Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words?  ( PDF File, 527 KB)
      Dean Schillinger, Edward L. Machtinger, Frances Wang, Lay-Leng Chen, Karen Win, Jorge Palacios, Maytrella Rodriguez, Andrew Bindman
Methodological Challenges in Describing Medication Dosing Errors in Children ( PDF File, 203 KB)
      Heather McPhillips, Christopher Stille, David Smith, John Pearson, John Stull, Julia Hecht, Susan Andrade, Marlene Miller, Robert Davis
Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings ( PDF File, 237 KB)
      K. Arnold Chan for the HMO Research Network CERT Patient Safety Investigators

Cognition, Systems, and Risk

Diagnostic Failure: A Cognitive and Affective Approach ( PDF File, 226 KB)
      Pat Croskerry
Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project ( PDF File, 247 KB)
      Gordon D. Schiff, Seijeoung Kim, Richard Abrams, Karen Cosby, Bruce Lambert, Arthur S. Elstein, Scott Hasler, Nela Krosnjar, Richard Odwazny, Mary F. Wisniewski, Robert A. McNutt
Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work ( PDF File, 809 KB)
      Christopher Nemeth, Michael O'Connor, P. Allan Klock, Richard Cook
Clinical Inertia and Outpatient Medical Errors ( PDF File, 333 KB)
      Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush, George Biltz
A Conceptual Framework for Studying the Safety of Transitions in Emergency Care ( PDF File, 197 KB)
      Ravi Behara, Robert L. Wears, Shawna J. Perry, Eric Eisenberg, Lexa Murphy, Mary vanderHoeff, Marc Shapiro, Christopher Beach, Pat Croskerry, Karen Cosby
Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology  (PDF File, 313 KB)
      Jiajie Zhang, Vimla L. Patel, Todd R. Johnson, Philip Chung, James P. Turley
Work System Analysis: The Key to Understanding Health Care Systems ( PDF File, 185 KB)
      Ben-Tzion Karsh, Samuel J. Alper
Observing Nurse Interaction with Infusion Pump Technologies ( PDF File, 250 KB)
      Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt, Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks, Tanita L. Robert, Myra Enloe, Rupa Sheth, Sade Sobande
Usability Testing and the Relation of Clinical Information Systems to Patient Safety ( PDF File, 260 KB)
      Michelle L. Rogers, Emily Patterson, Roger Chapman, Marta Render
Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation ( PDF File, 327 KB)
      David Anthony, VK Chetty, Anand Kartha, Kathleen McKenna, Maria Rizzo DePaoli, Brian Jack
Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities ( PDF File, 246 KB)
      Sharon Conrow Comden, David Marx, Margaret Murphy-Carley, Misti Hale
A Model-based Approach to Prioritizing Medical Safety Practices ( PDF File, 180 KB)
      Richard S. Marken

Safety Culture and Organizational Issues

Creating a Culture of Patient Safety through Innovative Hospital Design ( PDF File, 2.22 MB)
      John G. Reiling
From Science to Service: A Framework for the Transfer of Patient Safety Research into Practice ( PDF File, 213 KB)
      Veronica F. Nieva, Robert Murphy, Nancy Ridley, Nancy Donaldson, John Combes, Pamela Mitchell, Christine Kovner, Elizabeth Hoy, Deborah Carpenter
Making a Case for Organizational Change in Patient Safety Initiatives ( PDF File, 171 KB)
      Rangaraj Ramanujam, Donna J. Keyser, Carl A. Sirio
Organizational Climate of Staff Working Conditions and Safety—An Integrative Model ( PDF File, 220 KB)
      Patricia W. Stone, Michael I. Harrison, Penny Feldman, Mark Linzer, Timothy Peng, Douglas Roblin, Jill Scott-Cawiezell, Nicholas Warren, Eric S. Williams
A Conceptual Model for Disclosure of Medical Errors ( PDF File, 200 KB)
      Stephanie Fein, Lee Hilborne, Margie Kagawa-Singer, Eugene Spiritus, Craig Keenan, Gregory Seymann, Kaveh Sojania, Neil Wenger

Peer Reviewers—Volume 2

Volume 3. Implementation Issues

Prologue: Where the Rubber Meets the Road ( PDF File, 85 KB)
      Lucian L. Leape

Information Technology

Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care ( PDF File, 639 KB)
      Denise Hartnett Daudelin, Manlik Kwong, Joni R. Beshansky, Harry P. Selker
Improving Patient Safety with the Military Electronic Health Record ( PDF File, 496 KB)
      Marie-Jocelyne Charles, Bart J. Harmon, Pamela S. Jordan
Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study ( PDF File, 276 KB)
      Adrianne C. Feldstein, David H. Smith, Nan R. Robertson, Christine A. Kovach, Stephen B. Soumerai, Steven R. Simon, Dean F. Sittig, Daniel S. Laferriere, Mara Kalter
Looking for Trouble in All the Right Places: The Legal Implications Associated with "Electronic Signatures" and High-risk Clinical Situations ( PDF File, 225 KB)
      Gabriel J. Escobar, Bruce F. Folck, Marla N. Gardner, June Ma, Larry I. Palmer, Bryan Liang, Linda K. Nozick
Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments ( PDF File, 317 KB)
      Christie Teigland, Richard Gardiner, Hailing Li, Colene Byrne
Barriers Associated with Medication Information Handoffs ( PDF File, 224 KB)
      K. Bruce Bayley, Lucy A. Savitz, Glenn Rodriguez, William Gillanders, Steve Stoner

Surveillance

Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative ( PDF File, 246 KB)
      David R. West, John M. Westfall, Rodrigo Araya-Guerra, Laura Hansen, Javán Quintela, Rebecca VanVorst, Elizabeth W. Staton, Bethany Matthews, Wilson D. Pace
The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis ( PDF File, 194 KB)
      Robert L. Phillips, Susan M. Dovey, John S. Hickner, Deborah Graham, Michele Johnson
Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems ( PDF File, 220 KB)
      Ellen Flink, C. Lynn Chevalier, Angelo Ruperto, Peg Dameron, Frederick J. Heigel, Ruth Leslie, Janet Mannion, Robert J. Panzer
Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative ( PDF File, 184 KB)
      Carl A. Sirio, Donna J. Keyser, Heidi Norman, Robert J. Weber, Carlene A. Muto
Identifying Barriers to the Success of a Reporting System ( PDF File, 161 KB)
      Michelle L. Harper, Robert L. Helmreich
"Near-miss" Reporting System Development and Implications for Human Subjects Protection ( PDF File, 172 KB)
      Harvey J. Murff, Daniel W. Byrne, Paul A. Harris, Daniel J. France, Christa Hedstrom, Robert S. Dittus
The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data ( PDF File, 180 KB)
      William J. Rudman, Jessica H. Bailey, Carol Hope, Paula Garrett, C. Andrew Brown
Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System ( PDF File, 203 KB)
      Sharon K. Ulep, Sheryl L. Moran
Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program ( PDF File, 144 KB)
      Marilyn Flack, Terrie Reed, Jay Crowley, Susan Gardner
Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense ( PDF File, 140 KB)
      Mary Ann Davis, Geoffrey W. Rake

Interventions

The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care ( PDF File, 230 KB)
      Kimberly A. Galt, Ann M. Rule, Wendy Taylor, Mark Siracuse, J.D. Bramble, Eugene C. Rich, Wayne Young, Bartholomew Clark, Bruce Houghton
Implementation of an Evidence-based Protocol for Surgical Infection Prophylaxis ( PDF File, 194 KB)
      John A. Savino, Jane Smeland, Ellen L. Flink, Angelo Ruperto, Amanda Hines, Thomas Sullivan, Kerri Galvin, Donald A. Risucci
Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database ( PDF File, 191 KB)
      Elaine M. Furmaga, Peter A. Glassman, Francesca E. Cunningham, Chester B. Good
Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation? ( PDF File, 172 KB)
      Debra Quinn, Mary Cooper, Lynn Chevalier, Jerry Balentine, Lawrence Kadish, Steven Walerstein, Fredric Weinbaum, Mark Callahan, Eliot Lazar
Implementing a Systems Engineering Intervention for Improving Safety in Outpatient Surgeries ( PDF File, 360 KB)
      Pascale Carayon, Ann Schoofs Hundt, Carla J. Alvarado, Scott Springman, Amanda Borgsdorf, Lynn Jenkins
Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis ( PDF File, 154 KB)
      Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair, Mark Kirschbaum, Durand E. Burns
Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors ( PDF File, 191 KB)
      Steven H. Shaha, Linda Brodsky, Michael S. Leonard, Michael A. Cimino, Sandra A. McDougal, Joann M. Pilliod, Kristen E. Martin
Cost Effectiveness of a Multifaceted Program for Safe Patient Handling ( PDF File, 175 KB)
      Kris Siddharthan, Audrey Nelson, Hope Tiesman, FangFei Chen

Challenges and Lessons Learned

Patient Safety Data Sharing and Protection from Legal Discovery ( PDF File, 170 KB)
      Steven Suydam, Bryan A. Liang, Storm Anderson, Matthew B. Weinger
Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? ( PDF File, 170 KB)
      John D. Banja
Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change  (PDF File, 190 KB)
      Dwight McNeill, Howard Holland, Kerm Henriksen
From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator ( PDF File, 200 KB)
      Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, Richard H. White
Lessons in Safety Climate and Safety Practices from a California Hospital Consortium ( PDF File, 183 KB)
      Sara J. Singer, Kelly M. Dunham, Jennie D. Bowen, Jeffrey J. Geppert, David M. Gaba, Kathryn M. McDonald, Laurence C. Baker
Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense( PDF File, 440 KB)
      Heidi B. King, Beth Kohsin, Mary Salisbury
Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation ( PDF File, 490 KB)
      Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson
Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies ( PDF File, 185 KB)
      Deborah G. Graham, Wilson Pace, Jennifer Kappus, Sherry Holcomb, James M. Galliher, Christine W. Duclos, Aaron J. Bonham

Safety Improvement Initiatives

Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments ( PDF File, 197 KB)
      Elizabeth A. P. Vane, Edward Drost, Daryl Elder, Yvonne Heib
Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events ( PDF File, 403 KB)
      Sandra Ludwick
Voluntary Hospital Coalitions to Promote Patient Safety ( PDF File, 298 KB)
      Kimberly J. Rask, Dorothy "Vi" Naylor, Linda Schuessler
Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies ( PDF File, 253 KB)
      Laura Bonner, Bradford Felker, Edmund Chaney, Karen Vollen, Karen Berry, Barbara Revay, Barbara Simon, Lial Kofoed, Scott Ober, Linda Worley, John Fotiades, Scott Sherman
A New Model of Tracheostomy Care: Closing the Research-Practice Gap ( PDF File, 211 KB)
      Joel St. Clair

Peer Reviewers—Volume 3

Volume 4. Programs, Tools, and Products

Prologue: Blueprints for Action ( PDF File, 102 KB)
      Mary K. Wakefield

Programs and Collaborations

A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality's Patient Safety Initiative 2000-2004 ( PDF File, 195 KB)
      Margaret A. Keyes, Eduardo Ortiz, Deborah Queenan, Ronda Hughes, Francis Chesley, Eileen M. Hogan
Safe Practices for Better Health Care ( PDF File, 191 KB)
      Kenneth W. Kizer, Laura N. Blum
The San Diego Center for Patient Safety: Creating a Research, Education, and Community Consortium ( PDF File, 225 KB)
      Nancy Pratt, Kelly Vo, Theodore G. Ganiats, Matthew B. Weinger
Best Practices for Medical Technology Management: A U.S. Air Force-ECRI Collaboration ( PDF File, 135 KB)
      James P. Keller, Jr., Stephen Walker
A Clinical Assessment Program to Evaluate the Safety of Patient Care ( PDF File, 194 KB)
      Richard J. Snow, Martin S. Levine, Dwain L. Harper, Sharon L. McGill, George Thomas, Joseph P. McNerney
A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences ( PDF File, 497 KB)
      Dale A. Arroyo

Tools and Procedures

Development of a Planning Tool to Guide Research Dissemination ( PDF File, 327 KB)
Dissemination Planning Tool: Exhibit A ( PDF File, 440 KB; Text Version)
      Deborah Carpenter, Veronica Nieva, Tarek Albaghal, Joann Sorra
Physician Use of Hand-held Computers for Drug Information and Prescribing ( PDF File, 290 KB)
      Kimberly A. Galt, Mark V. Siracuse, Ann M. Rule, Bartholomew E. Clark, Wendy Taylor
A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement ( PDF File, 198 KB)
      R. B. Akins
Development of a Screening Tool for Safe Wheelchair Seating ( PDF File, 170 KB)
      Deborah Gavin-Dreschnack, Lawrence Schonfeld, Audrey Nelson, Stephen Luther
Speaking Plainly: Communicating the Patient's Role in Health Care Safety ( PDF File, 171 KB)
      David J. Miranda, Paula K. Zeller, Rosemary Lee, Christopher P. Koepke, Howard E. Holland, Farah Englert, Elaine K. Swift
Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety ( PDF File, 153 KB)
      Myra A. Kleinpeter

Simulation

The Use of Surgical Simulators to Reduce Errors ( PDF File, 824 KB)
      Marvin P. Fried, Richard Satava, Suzanne Weghorst, Anthony Gallagher, Clarence Sasaki, Douglas Ross, Mika Sinanan, Hernando Cuellar, Jose I. Uribe, Michael Zeltsan, Harman Arora
SimCare: A Model for Studying Physician Decisionmaking Activity( PDF File, 286 KB)
      Pradyumna Dutta, George R. Biltz, Paul E. Johnson, JoAnn M. Sperl-Hillen, William A. Rush, Jane E. Duncan, Patrick J. O'Connor
Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities ( PDF File, 268 KB)
      George Blike, Joseph Cravero, Steve Andeweg, Jens Jensen, Klaus Christoffersen

Education and Training

AHRQ WebM&M—Online Medical Error Reporting and Analysis ( PDF File, 205 KB)
      Robert M. Wachter, Kaveh G. Shojania, Tracy Minichiello, Scott A. Flanders, Erin E. Hartman
Patient Safety Executive Walkarounds ( PDF File, 182 KB)
      Suzanne Graham, John Brookey, Catherine Steadman
Combining Performance Feedback and Evidence-based Educational Resources ( PDF File, 207 KB)
      John R. Meurer, Linda N. Meurer, Jean Grube, Karen J. Brasel, Chris McLaughlin, Stephen Hargarten, Peter M. Layde
Medical Team Training Programs in Health Care ( PDF File, 243 KB)
      David P. Baker, Sigrid Gustafson, J. Mathew Beaubien, Eduardo Salas, Paul Barach
The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety ( PDF File, 180 KB)
      Ben-Tzion Karsh, Pascale Carayon, Maureen Smith, Kathleen Skibinski, Bruce Thomadsen, Patricia Flatley Brennan, Mary Ellen Murray
Expediting Clinician Adoption of Safety Practices: The UCSF Venous Access Patient Safety Interdisciplinary Education Project ( PDF File, 203 KB)
      Nancy E. Donaldson, Rosemary K. Plank, Ann Williamson, Jeffrey Pearl, Jerry Kellogg, Marcia Ryder
Creating a Curriculum for Training Health Profession Faculty Leaders ( PDF File, 714 KB)
      Pamela H. Mitchell, Lynne S. Robins, Douglas Schaad
An Ambulatory Care Curriculum for Advancing Patient Safety ( PDF File, 210 KB)
      Christel Mottur-Pilson
Developing a Taxonomy of Anesthetists' Nontechnical Skills (ANTS) ( PDF File, 185 KB)
      Rona Patey, Rhona Flin, Georgina Fletcher, Nicola Maran, Ronnie Glavin

Surveillance Tools

Serious Reportable Adverse Events in Health Care ( PDF File, 197 KB)
      Kenneth W. Kizer, Melissa B. Stegun
Physician Event Reporting: Training the Next Generation of Physicians ( PDF File, 136 KB)
      Quang-Tuyen Nguyen, Joanna Weinberg, Lee H. Hilborne
Standardizing Medication Error Event Reporting in the U.S. Department of Defense ( PDF File, 216 KB)
      Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake
Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings ( PDF File, 186 KB)
      Lucy A. Savitz, Cheryl B. Jones, Shulamit Bernard
The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents ( PDF File, 470 KB)
      Sandra Meadows, Karen Baker, Jeremy Butler
Technology for Improving Medication Monitoring in Nursing Homes ( PDF File, 411 KB)
      Kate L. Lapane, Kathleen Cameron, Janice Feinberg

Surveys

Online Patient Safety Climate Survey: Tool Development and Lessons Learned ( PDF File, 190 KB)
      Lynne M. Connelly, Judy L. Powers
Safety Climate on Hospital Units: A New Measure ( PDF File, 188 KB)
      Mary A. Blegen, Ginette A. Pepper, Joseph Rosse
Outpatient Surgery and Patient Safety—The Patient's Voice ( PDF File, 212 KB)
      Ann Schoofs Hundt, Pascale Carayon, Scott Springman, Maureen Smith, Kelly Florek, Rupa Sheth, Margaret Dorshorst
An Employee Questionnaire for Assessing Patient Safety in Outpatient Surgery ( PDF File, 215 KB)
      Pascale Carayon, Carla J. Alvarado, Ann Schoofs Hundt, Scott Springman, Amanda Borgsdorf, Peter L.T. Hoonakker
Development and Validation of the Medication Administration Error Reporting Survey ( PDF File, 280 KB)
      Bonnie J. Wakefield, Tanya Uden-Holman, Douglas S. Wakefield

Peer Reviewers—Volume 4

AHRQ Publication No. 05-0021-1 (Vol. 1)
AHRQ Publication No. 05-0021-2 (Vol. 2)
AHRQ Publication No. 05-0021-3 (Vol. 3)
AHRQ Publication No. 05-0021-4 (Vol. 4)