Patient Safety Research Highlights (continued, 2)

Program Brief

Organizational Change

Are critical pathways worth the money? Critical pathways are health care management plans that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80 percent of hospitals in the United States use critical pathways for at least some of their patients. AHRQ researchers assessed whether critical pathways have been successful in reducing patient length of stay and resource utilization. They found that most pathways reduced neither and cautioned that further evaluation of critical pathways is necessary before additional resources are consumed for this management strategy.
Project Title: Targeting Interventions to Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer, M.D.
Reference: Saint S, Hofer TP, Rose JS, Kaufman SR, McMahon LF Jr. Use of critical pathways to improve efficiency: a cautionary tale. Am J Manag Care 2003 Nov;9(11):758-65.

Pittsburgh guidelines for health system redesign developed successful strategies for improving patient safety. Fundamental changes are needed in the health care system to improve patient safety, but there is no commonly accepted blueprint for redesigning the system. AHRQ researchers examined the Pittsburgh Regional Healthcare Initiative (PRHI)—a health system redesign project that includes 44 hospitals in 12 counties in southwestern Pennsylvania, along with major insurers, health care purchasers, and civic leaders. Key features in this design are linking patient outcomes data with processes of care; sharing that information widely; real-time error reporting; and quick, decentralized problem solving among participating institutions . The study helped develop successful strategies for improving patient safety. Many PRHI recommended practices and guidelines have been disseminated regionally and are available at http://www.prhi.org.
Project Title: Systems Approach for Improving Region-Wide Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11926
Principal Investigator: Carl A. Sirio, M.D.
Reference: Sirio CA., Segel KT, Keyser DJ., et al. Pittsburgh Regional Healthcare Initiative: a systems approach for achieving perfect patient care. Health Aff 2003 Sep-Oct;22(5):157-65.

Preplanning enables well-defined courses of action and, at the same time, effectively handles unlikely events in the cardiac operating room. Plans and planning behavior by health professionals are fundamental to patient safety, but planned actions in health care are rarely static. Preparation facilitates effective, expected courses of action while accommodating real-world contingencies and unforeseen circumstances. An AHRQ study found that successful cardiac surgery requires having the right tools for the job in the right place at the right time, even in the face of unforeseen circumstances. AHRQ researchers collected and analyzed video and audio recordings of 20 surgical cases involving both coronary artery bypass surgery and heart valve replacement and described how preplanning enables well-defined courses of action and at the same time effectively handles unlikely events in the cardiac operating room.
Project Title: Ethnography of Transitions in Cardiac Care
AHRQ Grant: HS12003
Research Area: WC
Principal Investigator: Paul Gorman, M.D.
Reference: Hazlehurst B, McMullen C, Gorman P. Getting the right tools for the job: preparatory system configuration and active replanning in cardiac surgery. In: Santos E, Willett P, editors. IEEE International Conference on Systems, Man & Cybernetics. Vol 2. Piscataway, New Jersey; 2003. pp. 1784-91.

Using virtual patient care units may improve patient safety and outcomes. Research data from health care systems are usually complex and present information as a snapshot in time. This makes application difficult in a dynamically changing health care system. To transform complex data into information that nurses can use, AHRQ researchers used computational modeling, a set of tools that allows users to create a virtual model of a particular system such as a patient care unit. Based on real patient care units, they created 16 virtual units that are functionally similar to their real counterparts in key characteristics of the unit and patient safety outcomes.
Project Title: The Impact of Nursing Unit Characteristics on Outcomes
AHRQ Grant: HS11973
Research Area:WC
Principal Investigator: Joyce Verran, M.D.
Reference: Effken JA, Brewer BB, Patil A, Lamb GS, Verran JA, Carley KM. Using computational modeling to transform nursing data into actionable information. J Biomed Inform 2003 Aug-Oct;36(4-5):351-61.

Primary care offices can be made safer by emphasizing information systems, promoting a culture of quality, and improving the environment. The Minimizing Error, Maximizing Outcome (MEMO) Study used a conceptual model to relate office working conditions to quality of care, as mediated by physician reactions. Physician surveys assessed office environment and organizational climate. A chaotic office atmosphere was strongly associated with physician stress, a lack of quality emphasis was associated with past errors, and a lack of emphasis on information and communication was associated with a higher likelihood of future errors. AHRQ researchers found that primary care offices could be made safer by emphasizing information systems, promoting a culture of quality, and improving the environment.
Project Title: Minimizing Error, Maximizing Outcome (MEMO): The Physician Worklife Study II
AHRQ Grant: HS11955-03
Principal Investigator: Mark Linzer, M.D.
Reference: Linzer M, Manwell LB, Mundt M, Williams E, Maguire A, McMurray J, Plane MB. Organizational climate, stress, and error in primary care: the MEMO Study. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 1, Research Findings. AHRQ Publication No. 05-0021-1. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 65-77.

Do too many distractions affect nursing care? The acute care hospital environment is filled with numerous distractions. Within this environment, professional nurses make clinical judgments about their patients, whose conditions may change minute by minute. As a result, nurses constantly organize and reorganize the priorities and tasks of care to accommodate patients' fluctuating status. AHRQ researchers describe an ongoing research study aimed at exploring the effect of interruptions on the cognitive work of nursing. By combining human factors techniques and qualitative observation of nurses in practice, researchers produced a cognitive pathway, a unique visual graphic that offers a perspective of the nature of nurses' work and the effect of interruptions and cognitive load on omissions and errors in care.
Project Title:Work Environment: Effects on Quality of Healthcare
Research Area: WC
AHRQ Grant: HS11983
Principal Investigator: Bradley Evanoff, M.D., M.P.H.
Reference: Potter P, Wolf L, Boxerman S, Grayson D, Sledge J, Dunagan C, Evanoff B. An analysis of nurses' cognitive work: a new perspective for understanding medical errors. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 1, Research Findings. AHRQ Publication No. 05-0021-1. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 39-51.

*Learning-from-defects tool enhances safety by guiding realtime incident analysis and action planning. AHRQ researchers developed a systematic approach for practitioners and administrators to identify and explain systems that lead to defects in patient care. Similar to root cause analysis and for use in all settings of care, the Learning from Defects (LFD) tool provides a three-step process for prompt investigation of specific incidents of shortcomings in care. This tool also facilitates the development of incident-specific risk reduction strategies. The article includes an example copy of the tool, including a one-page user's guide, an example of a completed incident investigation form, and a model case summary—outlining major lessons learned, with corresponding safety tips to reduce the likelihood of the incident re-occurring.
Project Title: Intensive Care Unit Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter Pronovost, M.D., Ph.D.
Reference: Pronovost P, Holzmueller CG, Martinez E, Cafeo CL, Hunt D, Dickson C, Awad Michael, Makary MA. A practical tool to learn from defects in patient care. Jt Comm J Qual Pat Saf 2006 Feb;32(2):102-8.

*Patterns of patient-, medication and care-related factors can foreshadow hospitalized patients' risk of falling. Inpatient falls can lead to avoidable patient injuries and increased costs. However, few studies have assessed care-related and environmental factors associated with both elderly and nonelderly falls in hospitals. AHRQ researchers conducted a case-control study of 98 adult patients who fell while hospitalized. Patient-, medication-, and care-related factors that were significantly associated with an increased risk of falling included gait or lower extremity problems, confusion, use of sedatives or diabetes medications, and increased patient-to-nurse ratios. Eighty-five percent of patients under orders of "up only with assistance" were not using assistance when they fell. In addition to patient characteristics, fall prevention programs must address common care-related circumstances surrounding patients' falls.
Project Title: Surveillance, Analysis, and Interventions to Improve Patient Safety
Research Area: R-DEMO
AHRQ Grant: HS11898
Principal Investigator: Victoria Fraser, M.D.
Reference: Krauss MJ, Evanoff B, Hitcho E, Ngugi KE, Dunagan WC, Fischer I, Birge S, Johnson S, Costantinou E, Fraser VJ. A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med 2005 Feb;20(2):116-22.

The AIM quality improvement process can significantly reduce the incidence of pressure ulcers among nursing home residents. Quality improvement processes that target frontline caregivers, but lack active oversight by the administration, have had little success in reducing the incidence of pressure ulcers (PU) among nursing home residents. AHRQ researchers developed and implemented a three-pronged approach called AIM-ability enhancement, incentives, and management feedback-in a 136-bed Pennsylvania nursing home with a history of multiple Department of Health citations. AIM empowers management with the resources to: directly oversee and enforce skin care education among staff; provide staff with monetary incentives for reaching predetermined PU-related goals; and issue consistent, real-time feedback to employees. Over a 12-week intervention period, AIM reduced the incidence of PUs (at all stages) among the home's residents from 28 to 3 percent. Researchers conclude that quality improvement processes that empower management may overcome obstacles to improving the culture of nursing homes and resident care.
Project Title: Organization Change to Improve Nursing Home Environment
Research Area: WC
AHRQ Grant: HS11976
Principal Investigator: Jules Rosen, M.D.
Reference: Rosen J, Mittal V, Degenholtz H, Castle N, Mulsant BH, Hulland S, Nace D, Rubin F. Ability, incentives, and management feedback: organizational change to reduce pressure ulcers in a nursing home. J Am Med Dir Assoc 2006 May-Jun;7(3):141-6.

Staffing impacts the rate of worker injuries in long-term care. For nursing home employees, the workplace is fraught with hazards and, as institutions face increasing pressure to perform more efficiently, the response is often lower staffing levels, higher patient loads, and increased chances for worker injuries. AHRQ researchers examined the impact of staffing on worker injuries in all Medicare-approved nursing homes throughout Maryland, West Virginia, and Ohio. Total RN, licensed practical nurse, and nursing aide hours per resident day across the three states (ranging from 3.2 to 3.6 hours per resident day) showed a statistically significant association with worker injury rates in these homes. Each additional hour of nursing care per resident day was predicted to reduce worker injuries by as much as 2.4 injuries per 100 full-time workers. Past studies have demonstrated a clear link between worker injuries and turnover; thus, researchers point out that it is imperative to preserve worker well-being in the face of impending shortages in long-term care staff.
Project Title: Do Organizational Factors Influence Both Patient & Worker Outcomes?
Research Area: WC
AHRQ Grant: HS11990
Principal Investigator: Alison Trinkoff, M.P.H., Sc.D., Ph.D., F.A.A.N.
Reference: Trinkoff AM, Johantgen M, Muntaner C, Le R. Staffing and worker injury in nursing homes. Am J Public Health 2005 Jul;95(7):1220-5.

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Education and Training

National AHRQ Patient Safety Network Web site Continues to Grow. The Web site, AHRQ Patient Safety Network, or AHRQ PSNet, is a national "one-stop" portal of resources for improving patient safety and preventing medical errors. AHRQ PSNet is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The site provides a wide variety of patient safety resources, information on tools and conferences, and more. AHRQ PSNet users can customize the site around their unique interests and needs by creating a "My PSNet" page. In addition, weekly AHRQ PSNet updates are available to subscribers on patient safety findings, literature, tools, and conferences. Additionally, a carefully annotated collection of seminal patient safety journal articles resides in a "Classics" section. Visit the AHRQ PSNet at http://psnet.ahrq.gov/.

The successful AHRQ WebM&M continues to attract new users. The AHRQ WebM&M Web site publishes illustrative cases of medical errors on the Internet, accompanied by expert commentaries, references, and opportunities to earn continuing medical education (CME) credits and continuing educational units (CEUs). It also includes a section on perspectives on safety and a "Did You Know?" section. AHRQ WebM&M is modeled on hospital morbidity and mortality conferences; three cases are posted each month to illustrate diverse patient safety issues, and case discussions are provided. The Web site, which had more than 30,000 visitors in its most recent month, has become a very popular source for medical error case discussions and has garnered highly positive feedback. AHRQ WebM&M represents one of the most successful on-line journals involving patient safety and medical error discussions.
Project Title: Develop, Implement, Maintain, and Assess a National Electronic Web-based Morbidity and Mortality Conference Site AHRQ Project No: 290-01-0011
Principal Investigator: Robert Wachter, M.D.
Reference:Wachter RM, Shojania KG, Minichiello T, Flanders SA, Hartma EE. AHRQ WebM&M-online medical error reporting and analysis. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 4, Programs, Tools and Products. AHRQ Publication No. 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 211-21.

Improving patient safety through Web-based education. The National Patient Safety Foundation collaborated with physicians, nurses, patient representatives, and educators throughout the United States to develop a standard method of patient safety education. Three interactive educational modules were developed: one each for physicians, nurses, and patients. The physician's module offers a total of six continuing medical education (CME) credits, and the nurse's module offers continuing educational units (CEUs). The patient's module provides fundamental information to achieve safe patient care. The Web sites are:

  • Physicians: http://www.npsf.org/html/mcw/physicians.html
  • Nurses: http://www.npsf.org/html/mcw/nurses.html
  • Patients: http://www.npsf.org/html/patients_Web.html

Project Title: Improved Patient Safety through Web-Based Education
Research Area: Dis-ED
AHRQ Grant: HS12043
Principal Investigator:William Hendee, Ph.D.

Video monitoring of emergency care improves patient safety. Video recording is a powerful tool for documenting clinician performance and revealing safety and systems issues not identified by human observation. AHRQ researchers employed video recording to document the real emergency procedures and critical events in a trauma center and identified patient safety, clinical, quality assurance, and ergonomic issues, as well as systems failures. They suggest that video recording is a useful feedback and training tool and provides a reusable record of events that can be repeatedly reviewed and used as research data. In addition to improving patient safety, participation in video recording was beneficial to health care providers also, as they could review the universal precautions to protect themselves and develop best practices for emergency care.
Project Title: Brief Risky High Benefit Procedures: Best Practice Model
Research Area: SRBP
AHRQ Grant: HS11279
Principal Investigator: Colin Mackenzie, M.D.
Reference: Mackenzie CF, Xiao Y. Video techniques and data compared with observation in emergency trauma care. Qual Saf Health Care 2003 Dec;12:Suppl 2, ii51-7.

SimCare: An assessment and teaching tool for diabetes care. A major factor in the high rates of medical error in the treatment of patients with diabetes and other chronic diseases is the complexity of the tasks that physicians must complete. AHRQ researchers developed SimCare, a dynamic and interactive model that simulates diabetes management in the office-based practice setting. SimCare presents a series of cases based on clinical situations representing task features that are thought to be the source of both realistic care decisions and medical errors. Physicians select treatment options from an unguided set of choices similar to those available in routine office practice. The cumulative record of the chosen treatment moves is available for analysis and comparison with an expert's sequence of moves for each simulated patient. SimCare is potentially both an assessment and a teaching tool that enables the observation and analysis of physician decisionmaking in the simulated practice setting.
Project Title: Physician intervention to improve diabetes care.
AHRQ Grant: HS10639
Principal Investigator: Patrick J. O'Connor, M.D., M.P.H.
Reference: Dutta P, Biltz GR, Johnson PE, Sperl-Hillen JM, Rush WA, Duncan JE, O'Connor PJ. SimCare: a model for studying physician decisionmaking activity. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 4, Programs, Tools and Products. AHRQ Publication No. 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005. pp. 179-92.

Simulator provides a reliable assessment of technical skills vital to mastering minimally invasive endoscopic sinus surgeries. A simulator training curriculum was developed with the endoscopic sinus surgery simulator (ES3) and validated by 34 medical students and 4 otolaryngology residents. Technical errors were identified, quantified, used to train and monitor surgical performance, and used for outcomes analysis to improve patient safety. Examples of current validated metrics include: time-to-completion, errors, economy of motion, and psychomotor tracking. Correlation with psychometric parameters (perception, psychomotor, visiospatial, cognitive mapping, etc.) will be used to identify technical errors and to validate the simulator and the curriculum. Scores on the ES3, correlate highly with scores on previously validated measures of perceptual, visiospatial, and psychomotor performance.
Project Title: Identifying and Reducing Errors with Surgical Simulation
Research Area: CLIPS
AHRQ Grant: HS11866
Principal Investigator: Marvin Fried, M.D.
Reference: Arora H, Uribe J, Ralph W, Zeltsan M, Cuellar H, Gallagher A, Fried MP. Assessment of construct validity of the endoscopic sinus surgery simulator. Arch Otolaryngol Head Neck Surg 2005 Mar;131(3):217-221.

Discovering the cognitive causes of errors may help detection and prevention. AHRQ researchers studied the electronic recording and presentation of clinical information from a cognitive point of view, studying various levels of clinician expertise. The group found that structured (rather than narrative) data resulted in better recall and better inferences for novice and intermediate level clinicians. This suggests a need for structured data entry or effective natural language processing to structure the data to help reduce errors. In addition, various stakeholders (administrators, engineers, nurses, and physicians) interpret error causation differently, and there was a greater tendency to assign human blame to errors when errors were presented retrospectively.
Project Title: Mining Complex Clinical Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George Hripcsak, M.D.
Reference: Bakken S, Cimino JJ, Hripcsak G. Promoting patient safety and enabling evidence-based practice through informatics. Med Care 2004 Feb;42(2 Suppl):II49-56.

*National curriculum targets improvement in the culture of patient safety by developing interprofessional leadership and collaboration. AHRQ researchers participated in the creation of the Faculty Leadership in Interprofessional Education to Promote Patient Safety (FLIEPPS) curriculum, which consists of an online five-module handbook on best practices in patient safety and an optional for-purchases online patient safety tutorial. Themes addressed by the handbook include: patient safety basics, developing academic leadership, improving practice safety culture and the response to error, and applying principles of teaching and learning to encourage active participation in the curriculum.
Project Title: Faculty Leadership in Interprofessional Education to Promote Patient Safety (FLIEPPS)—A Collaborative Agreement with HRSA
Research Area: HRSA
AHRQ Grant: D50 HP 10006
Principal Investigator: Pamela Mitchell, Ph.D., R.N.
Reference: Mitchell PH, Robins LS, Schaad D. Creating a curriculum for training health profession leaders. In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation. Vol. 4. Programs, Tools, and Products. AHRQ Publication Number 05-0021-4. Rockville, MD: Agency for Healthcare Research and Quality, Feb. 2005. pp. 299-312. Web site: http://www.interprofessional.washington.edu/ptsafety/resources.asp

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Safety in Intensive Care Units (ICUs)

Complicated, error-prone devices are commonly used in ICUs. The volume of patient data, lighting level, ambient noise, and scheduling all result in provider and patient stress in ICUs. These difficult working conditions make errors more probable and are risk factors for provider burnout and negative outcomes for patients. AHRQ researchers identified auditory alarms on ICU equipment, ICU syndrome (delirium), and needlesticks as examples of such problems. They stress that basic lessons in ergonomics, human factors, and human performance fail to apply in the complex medical environment of the ICU and there is a lot of room for improvement—from easy access to the dialysis machine to adjusting the manpower schedule.
Project Title: Development Center for Patient Safety Research
Research Area: DCERPS
AHRQ Grant: HS11562
Principal Investigator: Yan Xiao, M.D.
Reference: Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care 2002 Aug;8(4):316-20.

Most airway events in ICUs are preventable. More than half of airway events such as coughing, spasms of the larynx, excessive salivation and breath holding, and other complications involving endotracheal tubes in ICUs are preventable, according to AHRQ researchers. To help limit the impact of these events, researchers suggest that prevention efforts focus on critically ill infants and patients with complex medical conditions. Also, ICU managers should ensure appropriate staffing to limit the impact of airway events when they occur.
Project Title: Intensive Care Unit Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS14246
Principal Investigator: Peter Pronovost, M.D.
Reference: Needham DM, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, Morlock LL, Pronovost PJ. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004 Nov;32(11):2227-33.

AHRQ researchers provide a practical framework for increasing safety in the ICU. Complex systems such as ICUs are breeding grounds for errors and the resulting adverse events because interdependent components interact in unexpected ways. Patients are cared for by many providers with varying levels of expertise across several disciplines, and these providers use highly sensitive and potentially dangerous technologies and medications. Such complex systems require careful planning, excellent teamwork and communication, and designed redundancies to recheck for proper care processes. AHRQ researchers provide a practical framework for improving patient safety.
Project Title: Statewide Efforts to Improve Care in Intensive Care Units
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter Pronovost, M.D.
Reference: Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med 2004 Jun 15;140(12):1025-33.

*Comprehensive unit-based safety program can improve safety climate and reduce length of stay and medication errors in the ICU. Patient safety initiatives are often limited by scarce data on the safety climate and by a failure to document improvements and motivate work unit staff. The comprehensive unit-based safety program (CUSP) is an eight-step program designed to overcome such weaknesses by empowering staff, prioritizing safety concerns, and measuring pre- and post-intervention levels of safety climate and rate of adverse events. AHRQ researchers implemented CUSP in two ICUs of an academic medical center. At the end of 6 months, staff reporting a positive safety climate increased from 35 percent to as much as 68 percent. Length of stay in each ICU decreased significantly by a full day, and medication errors in transfer orders were nearly eliminated.
Project Title: Intensive Care Unit Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902
Principal Investigator: Peter Pronovost, M.D., Ph.D.
Reference: Pronovost P, Weast B, Rosenstein B, Sexton JB, Holzmueller C, Paine L, Davis R, Rubin HR. Implementing and validating a comprehensive unit-based safety program. Journal of Patient Safety 2005. Mar;1(1):33-40.

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For More Information

For additional information on AHRQ-funded patient safety research and findings, please visit the AHRQ Web site at http://www.ahrq.gov/qual/patientsafetyix.htm or the Patient Safety Network at http://psnet.ahrq.gov or contact:

Jeff Brady
Patient Safety Portfolio Leader
AHRQ Center for Quality Improvement and Patient Safety
540 Gaither Road
Rockville, MD 20850
Telephone: (301) 427-1333
E-mail: Jeff.Brady@ahrq.hhs.gov


 

* Items marked with an asterisk (*) are new to this revised Program Brief.

Note: The Research Areas are different funding categories:

  • R-DEMO: Reporting System Demonstrations.
  • DCERPS: Developing Centers of Excellence in Research on Patient Safety.
  • HRSA: Health Resources and Services Administration.
  • SRBP: Systems-Related Best Practices.
  • WC: Effects of Working Conditions on Patient Safety.
  • CLIPS: Clinical Informatics and Patient Safety.
  • Dis-ED: Patient Safety Research Dissemination and Education.
  • COE: Centers of Excellence for Patient Safety Research and Practice.
  • TRIP: Translating Research into Practice.
  • CERTs: Centers for Education and Research on Therapeutics.
  • IDSRN: Integrated Delivery Systems Research Networks.
Current as of June 2009
Internet Citation: Patient Safety Research Highlights (continued, 2): Program Brief. June 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/factsheets/errors-safety/psresearch/psresearch3.html