Excerpt

To deliver high quality, safe care, health care stakeholders benefit from a set of approaches at their disposal. The approaches incorporated in this volume—representing programs, tools, and products to improve patient safety—cluster in five different areas: programs and collaborations, tools and procedures, simulation, education and training, and surveillance tools. Characterizing the attributes reflected in these papers illustrates the breadth of effort underway.

Contents

• Preface
• Acknowledgments
• Prologue: Blueprints for Action
• Programs and Collaborations
  • A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality's Patient Safety Initiative 2000-2004
    Margaret A. Keyes, Eduardo Ortiz, Deborah Queenan, Ronda Hughes, Francis Chesley, and Eileen M. Hogan.
    • Introduction
    • Background
    • Patient safety and the changing clinical environment
    • Overview of the six patient safety research solicitations released in 2001
    • Centers of Excellence
    • Clinical Informatics to Promote Patient Safety
    • Developing centers for patient safety research and practice
    • Effect of working conditions on patient safety
    • Health system error reporting, analysis, and safety improvement demonstrations
    • Patient safety research dissemination and education
    • Research themes
    • Managing and evaluating AHRQ's patient safety research initiative
    • New directions
    • 2003 safe practices implementation challenge grants
    • 2004 health care information technology and patient safety projects
    • Conclusions
    • Acknowledgments
    • References
  • Safe Practices for Better Health Care
    Kenneth W. Kizer and Laura N. Blum.
    • Introduction
    • Methods
    • Purpose of the consensus set of Safe Practices
    • Criteria for inclusion
    • Prioritizing the practices
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • The San Diego Center for Patient Safety: Creating a Research, Education, and Community Consortium
    Nancy Pratt, Kelly Vo, Theodore G. Ganiats, and Matthew B. Weinger.
    • Introduction
    • Laying the groundwork
    • Building a multidisciplinary team
    • Patient safety research
    • Patient safety education
    • Outreach to the community
    • Limitations and obstacles
    • Conclusions
    • Acknowledgments
    • References
  • Best Practices for Medical Technology Management: A U.S. Air Force-ECRI Collaboration
    James P. Keller Jr and Stephen Walker.
    • Introduction
    • Background
    • Medical device naming conventions
    • Management of hazards and recalls
    • Automated tracking of hazards and recalls
    • Acquisition and procurement of new technology
    • Inspection and preventive maintenance
    • Additional technology-related patient safety perspectives
    • Technology replacement
    • Conclusions
    • References
  • A Clinical Assessment Program to Evaluate the Safety of Patient Care
    Richard J. Snow, Martin S. Levine, Dwain L. Harper, Sharon L. McGill, George Thomas, and Joseph P. McNerney.
    • Introduction
    • The American Osteopathic Association Clinical Assessment Program (AOA-CAP)
    • Increasing participation
    • Evolving core competencies in the practice of medicine
    • How the AOA-CAP works
    • Project description
    • Benefits to family practice residency programs
    • A quality improvement tool
    • Initial findings
    • Results
    • Conclusions
    • Future directions
    • Acknowledgments
    • References
  • A Nonpunitive, Computerized System for Improved Reporting of Medical Occurrences
    Dale A. Arroyo.
    • Introduction
    • System description
    • System operation
    • Staff involvement
    • Barriers to overcome
    • System improvements and measures of success
    • Conclusion
    • Acknowledgments
    • References
• Tools and Procedures
  • Development of a Planning Tool to Guide Research Dissemination
    Deborah Carpenter, Veronica Nieva, Tarek Albaghal, and Joann Sorra.
    • Introduction
    • Purpose of the tool
    • Development and early testing
    • Description of the tool
    • Conclusion and future developments
    • Acknowledgments
    • References
  • Dissemination Planning Tool: Exhibit A
    Deborah Carpenter, Veronica Nieva, Tarek Albaghal, and Joann Sorra.
    • Purpose
    • Components of a Dissemination Plan
    • Instructions
    • I. Specifying Research Findings and Products: What You Intend to Disseminate
    • II. Identifying End Users
    • III. Working with Dissemination Partners
    • IV. Communicating Your Message
    • V. Evaluating Success
    • Developing A Summary
    • VI. Dissemination Work Plan
  • Physician Use of Hand-held Computers for Drug Information and Prescribing
    Kimberly A. Galt, Mark V. Siracuse, Ann M. Rule, Bartholomew E. Clark, and Wendy Taylor.
    • Introduction
    • Purpose
    • Methods
    • Results
    • Instrument
    • Behavioral intentions and actual use outcomes
    • Discussion
    • Limitations
    • Future research
    • Conclusion
    • Acknowledgments
    • References
  • A Process-centered Tool for Evaluating Patient Safety Performance and Guiding Strategic Improvement
    R. B. Akins.
    • Introduction
    • Methodology
    • Results
    • Inclusion criteria for final tool
    • Summary of findings
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Development of a Screening Tool for Safe Wheelchair Seating
    Deborah Gavin-Dreschnack, Lawrence Schonfeld, Audrey Nelson, and Stephen Luther.
    • Introduction
    • Method
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Speaking Plainly: Communicating the Patient's Role in Health Care Safety
    David J. Miranda, Paula K. Zeller, Rosemary Lee, Christopher P. Koepke, Howard E. Holland, Farah Englert, and Elaine K. Swift.
    • Introduction
    • Background
    • Consumer testing
    • Physician testing
    • Testing with consumers whose dominant language is Spanish
    • Development and testing of promotional materials
    • Annotated content from the five steps
    • Conclusion
    • Acknowledgments
    • References
  • Standardizing Ambulatory Care Procedures in a Public Hospital System to Improve Patient Safety
    Myra A. Kleinpeter.
    • Introduction
    • Problem statement
    • Approach
    • Patient identification
    • Communication
    • Medication safety
    • Target surgery
    • Infusion medication safety
    • Effective clinical alarm systems
    • Infection control
    • Key findings and interventions
    • Discussion
    • Conclusions
    • References
• Simulation
  • The Use of Surgical Simulators to Reduce Errors
    Marvin P. Fried, Richard Satava, Suzanne Weghorst, Anthony Gallagher, Clarence Sasaki, Douglas Ross, Mika Sinanan, Hernando Cuellar, Jose I. Uribe, Michael Zeltsan, and Harman Arora.
    • Introduction
    • Role of a surgical simulation
    • The endoscopic sinus surgery simulator
    • Metrics
    • Current ESS training
    • ES3 validation
    • VR to OR
    • Web-based data repository
    • Conclusion
    • Acknowledgments
    • References
  • SimCare: A Model for Studying Physician Decisionmaking Activity
    Pradyumna Dutta, George R. Biltz, Paul E. Johnson, JoAnn M. Sperl-Hillen, William A. Rush, Jane E. Duncan, and Patrick J. O'Connor.
    • Clinical decisions in diabetes care
    • The SimCare simulation
    • SimCare components
    • SimCare implementation
    • Validation and verification
    • Conceptual, operational, and face validity
    • SimCare experimental data
    • Summary and conclusion
    • Acknowledgments
    • References
  • Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities
    George Blike, Joseph Cravero, Steve Andeweg, Jens Jensen, and Klaus Christoffersen.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Education and Training
  • AHRQ WebM&M—Online Medical Error Reporting and Analysis
    Robert M. Wachter, Kaveh G. Shojania, Tracy Minichiello, Scott A. Flanders, and Erin E. Hartman.
    • Introduction
    • The evolution of AHRQ WebM&M
    • Results
    • Case submissions
    • Readers
    • User ratings of the site
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Patient Safety Executive Walkarounds
    Suzanne Graham, John Brookey, and Catherine Steadman.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Combining Performance Feedback and Evidence-based Educational Resources
    John R. Meurer, Linda N. Meurer, Jean Grube, Karen J. Brasel, Chris McLaughlin, Stephen Hargarten, and Peter M. Layde.
    • Introduction and background
    • The importance of data
    • Information to educate and create buy-in
    • Objective and program overview
    • Useful tools to prevent medical injuries
    • Methods
    • Evaluation
    • Preliminary results of hospital interventions
    • Discussion
    • Limitations
    • Conclusion
    • Acknowledgments
    • References
  • Medical Team Training Programs in Health Care
    David P. Baker, Sigrid Gustafson, J. Mathew Beaubien, Eduardo Salas, and Paul Barach.
    • Introduction
    • Simulator-based programs
    • Simulator-based program effectiveness
    • Classroom-based programs
    • Classroom-based program effectiveness
    • Empirical evidence
    • Case study results
    • Conclusions
    • Acknowledgments
    • References
  • The University of Wisconsin-Madison Multidisciplinary Graduate Certificate in Patient Safety
    Ben-Tzion Karsh, Pascale Carayon, Maureen Smith, Kathleen Skibinski, Bruce Thomadsen, Patricia Flatley Brennan, and Mary Ellen Murray.
    • Introduction
    • Educational efforts in patient safety
    • UW-Madison SEIPS graduate certificate in patient safety
    • The curriculum
    • Conclusions
    • Acknowledgments
    • References
  • Expediting Clinician Adoption of Safety Practices: The UCSF Venous Access Patient Safety Interdisciplinary Education Project
    Nancy E. Donaldson, Rosemary K. Plank, Ann Williamson, Jeffrey Pearl, Jerry Kellogg, and Marcia Ryder.
    • Introduction
    • The VAD threat to patient safety
    • VAD education in academic health professions education
    • Methods
    • Results
    • Conclusion
    • Acknowledgments
    • References
  • Creating a Curriculum for Training Health Profession Faculty Leaders
    Pamela H. Mitchell, Lynne S. Robins, and Douglas Schaad.
    • Introduction
    • Interprofessional collaboration is central to patient safety
    • Lack of interprofessional education related to patient safety
    • Approach
    • Process of curriculum development
    • Products
    • Conclusions
    • Acknowledgments
    • References
  • An Ambulatory Care Curriculum for Advancing Patient Safety
    Christel Mottur-Pilson.
    • Introduction
    • Implementation design
    • Method
    • Results
    • Discussion
    • Summary
    • Conclusion
    • Acknowledgments
    • References
  • Developing a Taxonomy of Anesthetists' Nontechnical Skills (ANTS)
    Rona Patey, Rhona Flin, Georgina Fletcher, Nicola Maran, and Ronnie Glavin.
    • Introduction
    • The ANTS System
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Surveillance Tools
  • Serious Reportable Adverse Events in Health Care
    Kenneth W. Kizer and Melissa B. Stegun.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Reducing the reporting burden
    • Use of reports based on the list
    • Quality improvement organizations
    • Consumers and purchasers
    • Unresolved issues and recommendations for research
    • Updating the list
    • Conclusion
    • References
  • Physician Event Reporting: Training the Next Generation of Physicians
    Quang-Tuyen Nguyen, Joanna Weinberg, and Lee H. Hilborne.
    • Introduction
    • Observations
    • Discussion
    • Recommendations
    • Conclusion
    • Acknowledgments
    • References
  • Standardizing Medication Error Event Reporting in the U.S. Department of Defense
    Ronald A. Nosek Jr, Judy McMeekin, and Geoffrey W. Rake.
    • Introduction
    • The Department of Defense response
    • Centralized reporting
    • Results
    • Types of error
    • Discussion
    • Lessons learned
    • Implementation
    • Education and training
    • System improvements
    • Conclusions
    • Acknowledgments
    • References
  • Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings
    Lucy A. Savitz, Cheryl B. Jones, and Shulamit Bernard.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Recommendations
    • Acknowledgments
    • References
  • The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents
    Sandra Meadows, Karen Baker, and Jeremy Butler.
    • Introduction
    • Why the tool has been developed
    • How the tool has been developed
    • How the tool works
    • The four tests
    • Unacceptable risk
    • Practical alternatives to suspension
    • Testing the model
    • Modifications
    • Preliminary findings
    • Where managers decided not to use the tool
    • The path forward
    • Conclusion
    • Acknowledgments
    • References
  • Technology for Improving Medication Monitoring in Nursing Homes
    Kate L. Lapane, Kathleen Cameron, and Janice Feinberg.
    • Introduction
    • Comprehensive geriatric assessment process
    • Geriatric Risk Assessment MedGuide™ (GRAM™)
    • Validity of GRAM software
    • Integration of GRAM into commercial pharmacy systems
    • Nursing home system change: integration of GRAM
    • Conclusion
    • Acknowledgments
    • References
• Surveys
  • Online Patient Safety Climate Survey: Tool Development and Lessons Learned
    Lynne M. Connelly and Judy L. Powers.
    • Introduction
    • Literature review
    • Purpose
    • Conceptual framework
    • Setting
    • Survey development and psychometrics
    • Survey administration
    • Findings of baseline assessment
    • Lessons learned
    • Limitations
    • Conclusions
    • Acknowledgments
    • References
  • Safety Climate on Hospital Units: A New Measure
    Mary A. Blegen, Ginette A. Pepper, and Joseph Rosse.
    • Introduction
    • Research on safety climate
    • Methods and results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Outpatient Surgery and Patient Safety— The Patient's Voice
    Ann Schoofs Hundt, Pascale Carayon, Scott Springman, Maureen Smith, Kelly Florek, Rupa Sheth, and Margaret Dorshorst.
    • Introduction
    • Background
    • Development of SEIPS
    • Methods
    • Methods
    • Respondents
    • Results
    • Symptom management
    • Education
    • Satisfaction
    • Overall assessment
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • An Employee Questionnaire for Assessing Patient Safety in Outpatient Surgery
    Pascale Carayon, Carla J. Alvarado, Ann Schoofs Hundt, Scott Springman, Amanda Borgsdorf, and Peter L.T. Hoonakker.
    • Introduction
    • Methods
    • Data analysis
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Development and Validation of the Medication Administration Error Reporting Survey
    Bonnie J. Wakefield, Tanya Uden-Holman, and Douglas S. Wakefield.
    • Introduction
    • Conceptual underpinnings
    • Why medication administration errors occur
    • Why medication administration errors are not reported
    • Survey development
    • Survey respondents
    • Psychometric properties
    • Reliability
    • Potential uses of the survey
    • Limitations
    • Conclusion
    • Acknowledgments
    • References
• Peer Reviewers—Volume 4

Suggested citation:

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.

Disclaimer: The authors of the papers published in this document are responsible for the content of each paper. Statements in the papers should not be construed as endorsements by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.