Advances in Patient Safety: New Directions and Alternative Approaches

Advances in Patient Safety: New Directions and Alternative Approaches represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and other topics related to improving patient safety.

The 115 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. The volumes are organized around four broad themes: volume 1, assessment; volume 2, culture and redesign; volume 3, performance and tools; and volume 4, information technology and medication safety. 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 tools and products that can be used to improve patient safety. This new publication complements AHRQ's Advances in Patient Safety: From Research to Implementation, published in 2005.

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Volume 1. Assessment
Volume 2. Culture and Redesign
Volume 3. Performance and Tools
Volume 4. Technology and Medication Safety

Volume 1. Assessment

Title Page and CitationPDF file PDF version - 18.35 KB )
Preface. Carolyn Clancy ( PDF file PDF version - 18.74 KB )
Acknowledgements ( PDF file PDF version - 56.89 KB )
Table of Contents ( PDF file PDF version - 56.89 KB )
Prologue to the Volume. Kerm Henriksen ( PDF file PDF version - 20.97 KB )

Looking Forward, Benefitting from the Past

Envisioning Patient Safety in 2025: Eight Perspectives ( PDF file PDF version - 82.71 KB
Kerm Henriksen, et al.

What Exactly is Patient Safety? ( PDF file PDF version - 555.33 KB )
Linda Emanuel, et al.

Reporting Systems

Improving the Value of Patient Safety Reporting Systems PDF file PDF version - 81.28 KB
Peter J. Provonost, et al.

The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data ( PDF file PDF version - 260.56 KB )
Katherine J. Jones, et al.

Proactive Post-Marketing Surveillance ( PDF file PDF version - 69.29 KB )
Robert R. Campbell, et al.

The Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks within the Larger Framework of MedSun ( PDF file PDF version - 100.3 KB )
Donna Engleman, et al.

Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology ( PDF file PDF version - 108.88 KB )
Martin November, et al..

26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System ( PDF file PDF version - 801.9 KB )
Debora Simmons, et al..

Using An Anonymous Web-based Incident Reporting Tool to Embed the Principles of a High Reliability Organization ( PDF file PDF version - 118.25 KB )
Paul Conlon, et al.

Voluntary Adverse Event Reporting in Rural Hospitals ( PDF file PDF version - 477.58 KB )
Charles P. Schade, et al.

Improving Error Reporting in Ambulatory Pediatrics with Team Approach ( PDF file PDF version - 357.68 KB )
Daniel R. Neuspiel, et al..

Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative ( PDF file PDF version - 91.37 KB )
David R. West, et al..

Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act ( PDF file PDF version - 211.47 KB )
William Riley, et al..

Taxonomies and Measurement

Development of a Comprehensive Medical Error Ontology ( PDF file PDF version - 892.83 KB )
Pallavi Mokkarala, et al.

Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy ( PDF file PDF version - 132.96 KB )
John R. Clarke, et al.

A System to Describe and Reduce Medical Errors in Primary Care ( PDF file PDF version - 447.48 KB )
Victoria Kaprielian,  et al.

Beyond Nursing Quality Measurement: The Nation's First Regional Nursing Virtual Dashboard ( PDF file PDF version - 1.04 MB )
Carolyn E. Aydin, et al.

Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance ( PDF file PDF version - 226.79 KB )
Paul Hougland, et al.

Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium ( PDF file PDF version - 569.7 KB )
Hude Quan, et al.

Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration ( PDF file PDF version - 222.08 KB )
Stephenie L. Shimada, et al.

Challenges and Lessons Learned

Patient Safety Learning Pilot: Narratives from the Frontlines ( PDF file PDF version - 608.01 KB )
Shirley E Kellie, et al.

A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care ( PDF file PDF version - 2.84 MB )
Ranjit Singh, et al.

Christiana Care Health System: Safety Mentor Program ( PDF file PDF version - 501.18 KB )
Michele Campbell, et al.

News Media and Health Care Providers at the Crossroads of Medical Adverse Events ( PDF file PDF version - 128.81 KB )
Pamela Whitten, et al.

Risk Assessment

Risk-Based Patient Safety Metrics ( PDF file PDF version - 613.81 KB )
Matthew C. Scanlon, et al.

Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning ( PDF file PDF version - 432.86 KB )
Donna M. Woods, et al.

A Model of Care Delivery to Reduce Falls in a Major Cancer Center ( PDF file PDF version - 425.82 KB )
Nancy E. Kline, et al.

Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care ( PDF file PDF version - 338.44 KB )
Mary L. Hook, et al.

Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings ( PDF file PDF version - 155.55 KB )
Robyn R.M. Gershon, et al.

Cause Analysis

The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (Advances 2 - Volume 1 - Faltz_56 )
Lawrence L. Faltz, et al.

Department of Veterans Affairs Emergency Airway Management Initiative ( PDF file PDF version - 104.14 KB )
Erik J. Stalhandske, et al.

Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities ( PDF file PDF version - 338.44 KB )
Patricia Ruddick, et al.

Common Cause Analysis: Focus on Institutional Change ( PDF file PDF version - 387.05 KB )
Anne Marie Browne, et al.

Peer Reviewers

Peer Reviewers—Volume 1 ( PDF file PDF version - 237 KB )

Volume 2. Culture and Redesign

Title Page and Citation ( PDF file PDF version - 18.34 KB )
Preface. Carolyn Clancy ( PDF file PDF version - 18.74 KB )
Acknowledgements ( PDF file PDF version - 17.04 KB )
Prologue to the Volume. James Battles ( PDF file PDF version - 19.54 KB )

Safety Culture and Organizational Issues

The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs ( PDF file PDF version - 750.3 KB )
Katherine J. Jones

Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture ( PDF file PDF version - 546.35 KB )
Karen L. Hannah, et al.

Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives ( PDF file PDF version - 133.36 KB )
Inga Adams-Pizarro, et al.

Measuring Safety Climate in Primary Care Offices ( PDF file PDF version - 603.13 KB )
Gurdev Singh, et al.

The PeaceHealth Ambulatory Medication Safety Culture Survey ( PDF file PDF version - 381.15 KB )
Ronald Stock, et al.

Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Healthcare System Following the National Standard of Care ( PDF file PDF version - 301.43 KB )
Hardeek H. Shah, et al.

Is There an Association between Patient Safety Indicators and Hospital Teaching Status? ( PDF file PDF version - 326.73 KB )
Peter E. Rivard, et al.

Organizational Behavior Management in Healthcare: Applications for Large-Scale Improvements in Patient Safety ( PDF file PDF version - 204.52 KB )
Thomas R. Cunningham, E. Scott Geller,

Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial ( PDF file PDF version - 154.33 KB )
Peter M. Layde, et al.

Clinical Process Improvement

Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World ( PDF file PDF version - 615.08 KB )
Stephen M. Borowitz, et al.

Documentation of Mandated Discharge Summary Components in Transitions from Acute to Sub-Acute Care ( PDF file PDF version - 97.39 KB )
Amy J. H. Kind, Maureen A. Smith

Challenges to Real-Time Decision Support in Healthcare ( PDF file PDF version - 263.23 KB )
Mark Fitzgerald, et al.

Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process ( PDF file PDF version - 667.02 KB )
Beverly Ann David, et al.

Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes From Paper to Electronic Systems ( PDF file PDF version - 452.16 KB )
Donald K. Baker, et al.

Promoting Best Practice and Safety through Preprinted Physician Orders ( PDF file PDF version - 199.36 KB )
George Ehringer, Barbara Duffy

The Impact of Standardized Order Sets on Quality and Financial Outcomes ( PDF file PDF version - 585.92 KB )
David J Ballard, et al.

Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility ( PDF file PDF version - 431.36 KB )
Kathy M. Harney, et al.

Creating Safety in the Testing Process in Primary Care Offices ( PDF file PDF version - 413.97 KB )
Nancy C. Elder, et al.

Role of the External Coach in Advancing Research Translation in Hospital-based Performance Improvement ( PDF file PDF version - 158.27 KB )
Nancy Donaldson, et al.

Strategies for Improving Patient Safety in Small Rural Hospitals ( PDF file PDF version - 133.99 KB )
Judith Tupper, et al.

Systems Redesign

Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work ( PDF file PDF version - 91 KB )
Julie K. Johnson, et al.

Designing the Built Environment for the Culture and System of Patient Safety-A Conceptual, New Design Process ( PDF file PDF version - 489.09 KB )
Kenneth N. Dickerman, Paul Barach

Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption ( PDF file PDF version - 598.36 KB )
Heather Woodward Hagg, et al.

Transforming the Morbidity and Mortality Conference into an Instrument for System-wide Improvement ( PDF file PDF version - 359.48 KB )
Jamie N. Deis, et al.

Collaboratives and Patient Involvement

The Patient Safety Education Project: An International Collaboration ( PDF file PDF version - 485.27 KB )
Linda Emanuel, et al.

Harnessing the Potential of Healthcare Collaboratives: Lessons from the Keystone ICU Project ( PDF file PDF version - 116.93 KB )
Christine Goeschel, et al.

VHA's National Falls Collaborative and Prevention Programs ( PDF file PDF version - 578.4 KB )
Erik Stalhandske, et al.

Hospital Language Services: Quality Improvement and Performance Measures ( PDF file PDF version - 127.93 KB )
Marsha Regenstein, et al.

Using Patient Complaints to Promote Patient Safety ( PDF file PDF version - 414.64 KB )
James W. Pichert, et al.

From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety ( PDF file PDF version - 619.64 KB )
Diane Valade, et al.

The Rural Physician Peer Review Model: A Virtual Solution ( PDF file PDF version - 422.26 KB )
Josie Williams, et al.

Peer Reviewers

Peer Reviewers—Volume 2 ( PDF file PDF version - 237.05 KB )

Volume 3. Performance and Tools

Title Page and Citation ( PDF file PDF version - 18.34 KB )
Preface. Carolyn Clancy ( PDF file PDF version - 18.74 KB )
Acknowledgements ( PDF file PDF version - 17.04 KB )
Table of Contents ( PDF file PDF version - 20.62 KB )
Prologue to the Volume. Margaret Keyes ( PDF file PDF version - 20.62 KB )

Teamwork and Communication

TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety ( PDF file PDF version - 466.33 KB
Heidi B. King, et al.

Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement with Promising Teamwork Tools and Strategies ( PDF file PDF version - 455.14 KB )
John S. Webster, et al.

Building Self-Empowered Teams for Improving Safety in Post-operative Pain ( PDF file PDF version - 1.02 MB )
Ranjit Singh, et al.

Beyond Rapid Response Teams: Instituting a "Rover Team" Improves the Management of At Risk Patients, Facilitates Proactive Interventions and Improves Outcomes ( PDF file PDF version - 598.42 KB )
Remi M. Hueckel, et al.

Improving Referral Communication Using a Referral Tool Within an Electronic Record ( PDF file PDF version - 156.27 KB )
Tejal K. Gandhi, et al.

Improving Patient Safety through Provider Communication Strategy Enhancements ( PDF file PDF version - 594.87 KB )
Catherine Dingley, et al.

Improving Clinical Communication and Patient Safety: Clinician Recommended Solutions ( PDF file PDF version - 149.86 KB )
Donna M. Woods, et al.


In Situ Simulation: Challenges and Results ( PDF file PDF version - 144.34 KB
Mary D. Patterson, et al.

The Nature, Characteristics and Patterns of Perinatal Critical Events Teams ( PDF file PDF version - 354.85 KB )
William Riley, et al.

Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding of Risks and Failures ( PDF file PDF version - 134.77 KB )
Stanley Davis, et al.

The Mobile Mock Operating Room: Bringing Team Training to the Point of Care ( PDF file PDF version - 1.49 MB
John T. Paige, et al.

Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training ( PDF file PDF version - 1,010.83 KB )
Ramnarayan Paragi Gururaja, et al.

Effect of Recent Refresher Training on In Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance ( PDF file PDF version - 648.44 KB )
Akira Nishisaki, et al.

Simulation-Based Education Improves Patient Safety in Ambulatory Care ( PDF file PDF version - 581.31 KB )
Beth A. LaVelle, et al.

Human Factors

Pillars of a Smart, Safe Operating Room ( PDF file PDF version - 108.54 KB )
F. Jacob Seagull, et al.

High Hanging Fruit: Improving Transitions in Healthcare ( PDF file PDF version - 100.13 KB )
Shawna J. Perry, et al.

Minding the Gaps: Creating Resilience in Healthcare ( PDF file PDF version - 550.18 KB )
Christopher Nemeth, et al.

Error Producing Conditions in the Intensive Care Unit ( PDF file PDF version - 474.99 KB )
Frank A. Drews, et al.

Patient Monitors in Critical Care: Lessons for Improvement ( PDF file PDF version - 121.63 KB )
Frank A. Drews

Tools and Practices

Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The Re-Engineered Discharge (RED) Program ( PDF file PDF version - 150.71 KB )
Brian Jack, et al.

Creating an Accurate Medication List in the Outpatiet Setting Through a Patient-Centered Approach ( PDF file PDF version - 143.27 KB )
Kathryn Kraft Leonhardt, et al.

The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems ( PDF file PDF version - 502.19 KB )
Gregg S. Meyer, et al.

Using Data Mining to Predict Errors in Chronic Disease Care ( PDF file PDF version - 660 KB )
Ryan M. McCabe, et al.

Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety ( PDF file PDF version - 133.92 KB )
Brenda K. Zierler, et al.

Using Process Measures to Improve Patient Safety Practices to Prevent Pulmonary Embolism ( PDF file PDF version - 437.55 KB )
Ellen Flink, et al.

A Tool to Assess Compliance in Anticoagulation Management ( PDF file PDF version - 585.37 KB )
Carla S. Huber, et al.

Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories within a Community ( PDF file PDF version - 437.55 KB )
Brion Hurley, et al.

Using Six Sigma® Methodology to Improve Handoff Communication in High Risk Patients ( PDF file PDF version - 585.37 KB )
Kshitij P. Mistry, et al.

10 Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma, and Team Training All Thrive in a Single Hospital? ( PDF file PDF version - 509.86 KB )
Jon N. Meliones, et al.

Impact of Staff-Led Safety Walk Rounds ( PDF file PDF version - 378.79 KB )
Vicki L. Montgomery, et al.

Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) ( PDF file PDF version - 675.68 KB )
Niraj L. Sehgal, et al.

Peer Reviewers

Peer Reviewers—Volume 3 ( PDF file PDF version - 237.08 KB )

Volume 4. Technology and Medication Safety

Title Page and Citation ( PDF file PDF version - 18.34 KB )
Preface. Carolyn Clancy ( PDF file PDF version - 18.74 KB )
Acknowledgements ( PDF file PDF version - 17.04 KB )
Table of Contents ( PDF file PDF version - 91.14 KB )
Prologue to the Volume. Mary Grady ( PDF file PDF version - 21.07 KB )

Health Information Technology

"Safeware": Safety-critical Computing and Healthcare Information Technology ( PDF file PDF version - 108.92 KB
Robert L. Wears, et al.

Improving Perioperative Patient Safety ( PDF file PDF version - 96.64 KB )
Paul St. Jacques, and Michael Minear

The Impact of Health Information Technology on Work Process and Patient Care on Labor and Delivery ( PDF file PDF version - 606.42 KB )
Emily M. Campbell, et al.

Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine ( PDF file PDF version - 455.22 KB )
Stephenie Loux, et al.

Personal Health Records to Improve Health Information Exchange and Patient Safety ( PDF file PDF version - 802.96 KB )
James R. Fricton, Diane Davie

Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opiod Therapy for Chronic Pain Experience ( PDF file PDF version - 535.76 KB )
Martha Michel, et al.

Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences ( PDF file PDF version - 120.83 KB )
Emily B. Devine, et al.

Measuring IT Sophistication in Nursing Homes ( PDF file PDF version - 215.97 KB )
Gregory L. Alexander, et al.

The Potential of Hand-held Assistive Technology to Improve Safety for Elder Adults Aging in Place ( PDF file PDF version - 728.42 KB )
Shirley Ann Becker, Frank M. Webbe.

Efficiency Gains with Computerized Provider Order Entry ( PDF file PDF version - 76.28 KB )
Andrew M. Steele, et al.

Medication Safety

Clinical Pharmacists in Emergency Medicine ( PDF file PDF version - 116.32 KB )
Rollin J. Fairbanks, et al.

Intravenous Infusion Safety Initiative: Collaboration, Evidence-based Best Practices and "Smart" Technology Help Avert High-risk Adverse Drug Events and Improve Patient Outcomes ( PDF file PDF version - 486.17 KB )
Ray Maddox, et al.

Continuous Respiratory Monitoring and "Smart" Infusion System Improve Safety of Patient-Controlled Anesthesia in the Postoperative Period ( PDF file PDF version - 724 KB )
Ray R. Maddox, et al.

Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods ( PDF file PDF version - 646.24 KB )
Andrew L. Masica, et al.

Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study ( PDF file PDF version - 116.03 KB )
John Lynch, et al.

Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes ( PDF file PDF version - 74.66 KB )
Karla Miller, et al.

Imbedding Research in Practice to Improve Medication Safety ( PDF file PDF version - 181.7 KB )
Marsha A. Raebel, et al.

Risk of Concurrent Use of Prescription Drugs with Herbal and Dietary Supplements in Ambulatory Care ( PDF file PDF version - 176.63 KB )
Robert E. Graham, et al.

Using Home Visits to Understand Medication Errors in Children ( PDF file PDF version - 621.47 KB )
Kathleen E. Walsh, et al.

Developing a Community-Wide Electronic Shared Medication List ( PDF file PDF version - 608.36 KB )
Ron Stock, et al.

Peer Reviewers

Peer Reviewers—Volume 4 ( PDF file PDF version - 236.15 KB )

Page last reviewed March 2017
Page originally created September 2012
Internet Citation: Advances in Patient Safety: New Directions and Alternative Approaches. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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