Excerpt

The contents of this volume, summarizing AHRQ- and other government-sponsored patient safety research over the past 5 years, demonstrates solid, broad, and rapid progress in the other key element upon which successful execution will rest: ideas. Here you will find every dimension of safe patient care delivery, ranging from state-of-the-art detection and tracking systems (concurrent and retrospective clinical trigger systems), to successful interventions that addressed specific, single injury sources (e.g., adverse drug events), to organizational structures (e.g., building a culture of safety; nursing roles; teamwork), to safety features within and among care delivery locales (e.g., rural versus urban care; ambulatory versus inpatient care; patient transitions), to core theory (e.g., human factors; cognitive factors; work load; transitory work assignments), to the role of technology (decision-support systems for safe care; methods to safely deploy new technologies), to the role of national and State-level policy.

Contents

• Preface
• Acknowledgments
• Prologue: Five Years Later—Are We Any Safer?
• The Clinical Environment
  • Can We Talk? Priorities for Patient Care Differed Among Health Care Providers
    Bradley Evanoff, Patricia Potter, Laurie Wolf, Deborah Grayson, Clay Dunagan, and Stuart Boxerman.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians
    Timothy J. Hoff, Henry Pohl, and Joel Bartfield.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • An Analysis of Nurses' Cognitive Work: A New Perspective for Understanding Medical Errors
    Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, and Bradley Evanoff.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • Reference
  • Do Transient Working Conditions Trigger Medical Errors?
    Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, and Bradley Evanoff.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Organizational Climate, Stress, and Error in Primary Care: The MEMO Study
    Mark Linzer, Linda Baier Manwell, Marlon Mundt, Eric Williams, Ann Maguire, Julia McMurray, and Mary Beth Plane.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Seamless Care: Safe Patient Transitions from Hospital to Home
    Andrea M. Spehar, Robert R. Campbell, Carron Cherrie, Polly Palacios, Donna Scott, Jacquelyn L. Baker, Brad Bjornstad, and Jay Wolfson.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
• Medication Safety
  • Best Practices in Medication Safety: Areas for Improvement in the Primary Care Physician's Office
    Kimberly A. Galt, Ann M. Rule, Bartholomew E. Clark, James D. Bramble, Wendy Taylor, and Kevin G. Moores.
    • Introduction
    • Objective
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • Reference
  • Quantitative and Qualitative Analysis of Medication Errors: The New York Experience
    Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink, and Ruth Leslie.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Reporting of Adverse Drug Events: Examination of a Hospital Incident Reporting System
    Radhika Desikan, Melissa J. Krauss, W. Claiborne Dunagan, Erin Christensen Rachmiel, Thomas Bailey, and Victoria J. Fraser.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Prescribing Safety in Ambulatory Care: Physician Perspectives
    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, and Joseph V. Selby.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Impact of Pharmacy-led Dyslipidemia Interventions on Medication Safety and Therapeutic Failure in Patients
    Joseph G. Weaver, Judy Enders McManus, Tammy Leung, Rhonda B. Mangione, Heidi R. Snow, and Stacie K. Hackworth.
    • Introduction
    • Methods
    • Results
    • Conclusion
    • Acknowledgments
    • References
  • Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs
    Dustin D. French, Andrea M. Spehar, Robert R. Campbell, Polly Palacios, Roy W. Coakley, Nicholas Coblio, Heidi Means, Dennis C. Werner, and David M. Angaran.
    • Introduction
    • Materials and methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Preventing Medication Errors in Ambulatory Care: The Importance of Establishing Regimen Concordance
    Dean Schillinger, Eddie Machtinger, Frances Wang, Maytrella Rodriguez, and Andrew Bindman.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics
    Valerie J. Riege.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Surveillance
  • Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM Code Classifications
    Carol J. Masheter, Paul Hougland, and Wu Xu.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Surveillance of Surgery-related Adverse Events in Missouri Using ICD-9-CM Codes
    Mark Van Tuinen, Susan Elder, Carolyn Link, Susan Li, John H. Song, and Tracey Pritchett.
    • Introduction
    • Methods
    • Analysis
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Developing a Veterans Health Administration (VHA) Serious Injury Surveillance System that Includes Adverse Event Hospitalizations
    Robert R. Campbell, Douglas D. Bradham, Aurora Sanchez-Anguiano, Dennis H. Werner, Andrea M. Spehar, Dustin French, and Polly Palacios.
    • Introduction
    • Methods
    • Analyses
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • A Study of Adverse Occurrences and Major Functional Impairment Following Surgery
    Mary Rojas, Alan Silver, Christine Llewellyn, and Lenora Rances.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Measuring Safety: A New Perspective on Outcomes of a Long-term Intensive Case Management Program
    Rosa M. Cotayo, Holly A. Grems, and Elizabeth Sloan.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Limitations
    • Conclusions
    • Acknowledgments
    • References
  • The Impact of a Patient Safety Program on Medical Error Reporting
    Donald R. Woolever.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
• Technology
  • Making Information Technology a Team Player in Safety: The Case of Infusion Devices
    Christopher Nemeth, Mark Nunnally, Michael O'Connor, P. Allan Klock, and Richard Cook.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Post-fielding Surveillance of a Guideline-based Decision Support System
    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, and Mary K. Goldstein.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • The Role of Patient Safety in the Device Purchasing Process
    Todd R. Johnson, Jiajie Zhang, Vimla L. Patel, Alla Keselman, Xiaozhou Tang, Juliana J. Brixey, Danielle Paige, and James P. Turley.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Ambulatory and Rural
  • Learning from Errors in Ambulatory Pediatrics
    Julie J. Mohr, Carole M. Lannon, Kathleen A. Thoma, Donna Woods, Eric J. Slora, Richard C. Wasserman, and Lynne Uhring.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Identification, Classification, and Frequency of Medical Errors in Outpatient Diabetes Care
    Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, and William A. Rush.
    • Introduction
    • Subjects and methods
    • Results
    • Discussion
    • References
  • From Here to There: Lessons from an Integrative Patient Safety Project in Rural Health Care Settings
    Ann Freeman Cook, Helena Hoas, and Katarina Guttmannova.
    • Introduction
    • Materials and Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Comparing Patient Safety in Rural Hospitals by Bed Count
    Stephenie L. Loux, Susan M. C. Payne, and Astrid Knott.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Policy and Medical Expenditures
  • Regulation of Health Policy: Patient Safety and the States
    Joanna Weinberg, Lee H. Hilborne, and Quang-Tuyen Nguyen.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Note
    • Acknowledgments
    • References
  • What Happens After a Patient Safety Event? Medical Expenditures and Outcomes in Medicare
    William E. Encinosa and Fred J. Hellinger.
    • Introduction
    • Background
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Financial and Demographic Influences on Medicare Patient Safety Events
    Didem Bernard and William E. Encinosa.
    • Introduction
    • Method
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Peer Reviewers—Volume 1

Suggested citation:

Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implemtation. Vol. 1, Research findings. AHRQ Publication No. 05-0021-1. 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.