Excerpt

Traditionally, a primary focus of patient safety research has been to analyze data to identify problems and demonstrate that a new practice will lead to improved quality or safety. Much less research attention has been paid to the details of actually implementing the new practices. This volume begins to remedy that shortcoming.

Implementation issues are, in a sense, “where it's at” for patient safety. Only by putting into practice what we learn in our research will we make care safer. However, it turns out to be very, very difficult. The challenge is threefold: 1) What is the right thing to do? Which practices improve safety? What is the evidence? 2) How do we do the right thing? What changes in our procedures and systems are needed to implement the new practice? 3) How do we make sure that the right thing is done 100 percent of the time? What is required to ensure full compliance of all parties, every time, without fail?

This volume focuses on the second step, implementation: how do we change our care patterns to incorporate a new practice? The third challenge, getting to full compliance, is left for another day.

Contents

• Preface
• Acknowledgments
• Prologue: Where the Rubber Meets the Road
• Information Technology
  • Using Specialized Information Technology to Reduce Errors in Emergency Cardiac Care
    Denise Hartnett Daudelin, Manlik Kwong, Joni R. Beshansky, and Harry P. Selker.
    • Introduction
    • Project overview
    • Patient safety alerts
    • Site selection
    • Development, implementation, and testing of the TIPI-IS
    • Successes and lessons learned
    • Conclusion
    • Disclosure
    • References
  • Improving Patient Safety with the Military Electronic Health Record
    Marie-Jocelyne Charles, Bart J. Harmon, and Pamela S. Jordan.
    • Introduction
    • The Military Health System
    • MHS information management and technology systems
    • Computerized Provider Order Entry (CPOE) foundation
    • Electronic Health Record improves on CPOE
    • Core capabilities of military EHR improve patient safety
    • Keys to successful EHR implementation
    • Conclusion
    • Acknowledgments
    • References
  • Decision Support System Design and Implementation for Outpatient Prescribing: The Safety in Prescribing Study
    Adrianne C. Feldstein, David H. Smith, Nan R. Robertson, Christine A. Kovach, Stephen B. Soumerai, Steven R. Simon, Dean F. Sittig, Daniel S. Laferriere, and Mara Kalter.
    • Introduction
    • Methods
    • Results
    • Discussion and conclusions
    • Acknowledgments
    • References
  • Looking for Trouble in All the Right Places: The Legal Implications Associated with “Electronic Signatures” and High-risk Clinical Situations
    Gabriel J. Escobar, Bruce F. Folck, Marla N. Gardner, June Ma, Larry I. Palmer, Bryan Liang, and Linda K. Nozick.
    • Introduction
    • Design and results
    • Interactions with our parent organizations
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure Ulcers in Nursing Home Environments
    Christie Teigland, Richard Gardiner, Hailing Li, and Colene Byrne.
    • Introduction
    • Method
    • Results
    • Conclusion
    • Acknowledgments
    • References
  • Barriers Associated with Medication Information Handoffs
    K. Bruce Bayley, Lucy A. Savitz, Glenn Rodriguez, William Gillanders, and Steve Stoner.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Surveillance
  • Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative
    David R. West, John M. Westfall, Rodrigo Araya-Guerra, Laura Hansen, Javán Quintela, Rebecca VanVorst, Elizabeth W. Staton, Bethany Matthews, and Wilson D. Pace.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis
    Robert L. Phillips, Susan M. Dovey, John S. Hickner, Deborah Graham, and Michele Johnson.
    • Introduction
    • Background
    • The AAFP error-reporting system: AAFP Patient Safety Reports
    • Legal and practical barriers to voluntary reporting
    • Conclusion
    • Acknowledgments
    • References
  • Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems
    Ellen Flink, C. Lynn Chevalier, Angelo Ruperto, Peg Dameron, Frederick J. Heigel, Ruth Leslie, Janet Mannion, and Robert J. Panzer.
    • Introduction
    • History and development of NYPORTS
    • Key characteristics of NYPORTS
    • Data utilization and comparisons
    • Impact of reporting systems on patient safety
    • Evolution of NYPORTS— Continuous Quality Improvement
    • Dissemination of information and analysis
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Shared Learning and the Drive to Improve Patient Safety: Lessons Learned from the Pittsburgh Regional Healthcare Initiative
    Carl A. Sirio, Donna J. Keyser, Heidi Norman, Robert J. Weber, and Carlene A. Muto.
    • Introduction
    • PRHI's regionwide shared learning model
    • Environmental factors
    • Safety culture
    • Safety infrastructure
    • Establishing regionwide patient safety goals
    • Implementing regionwide information sharing
    • Implementing regionwide problem-solving
    • Conclusions
    • Acknowledgments
    • References
  • Identifying Barriers to the Success of a Reporting System
    Michelle L. Harper and Robert L. Helmreich.
    • Introduction
    • Method
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • “Near-miss” Reporting System Development and Implications for Human Subjects Protection
    Harvey J. Murff, Daniel W. Byrne, Paul A. Harris, Daniel J. France, Christa Hedstrom, and Robert S. Dittus.
    • Background
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • The Impact of a Web-based Reporting System on the Collection of Medication Error Occurrence Data
    William J. Rudman, Jessica H. Bailey, Carol Hope, Paula Garrett, and C. Andrew Brown.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System
    Sharon K. Ulep and Sheryl L. Moran.
    • Introduction
    • Ten Considerations
    • Conclusion
    • Acknowledgments
    • References
  • Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program
    Marilyn Flack, Terrie Reed, Jay Crowley, and Susan Gardner.
    • Introduction
    • Building a new reporting system
    • Current status
    • Conclusion
    • References
  • Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense
    Mary Ann Davis and Geoffrey W. Rake.
    • Introduction
    • Background
    • Organizational structure: military health system
    • Spreadsheet design and implementation
    • Patient safety database
    • Patient safety data collection
    • Patient safety data analysis
    • Conclusion
    • Acknowledgments
    • Glossary
    • References
• Interventions
  • The Impact of Personal Digital Assistant Devices on Medication Safety in Primary Care
    Kimberly A. Galt, Ann M. Rule, Wendy Taylor, Mark Siracuse, J.D. Bramble, Eugene C. Rich, Wayne Young, Bartholomew Clark, and Bruce Houghton.
    • Introduction
    • Methods
    • Analysis
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Implementation of an Evidence-based Protocol for Surgical Infection Prophylaxis
    John A. Savino, Jane Smeland, Ellen L. Flink, Angelo Ruperto, Amanda Hines, Thomas Sullivan, Kerri Galvin, and Donald A. Risucci.
    • Introduction
    • Methods
    • Results of the intervention
    • Conclusions
    • Acknowledgments
    • References
  • Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database
    Elaine M. Furmaga, Peter A. Glassman, Francesca E. Cunningham, and Chester B. Good.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation?
    Debra Quinn, Mary Cooper, Lynn Chevalier, Jerry Balentine, Lawrence Kadish, Steven Walerstein, Fredric Weinbaum, Mark Callahan, and Eliot Lazar.
    • Introduction
    • Background
    • Patient factors
    • Provider factors
    • Organizational factors
    • Conclusion
    • Acknowledgments
    • References
  • Implementing a Systems Engineering Intervention for Improving Safety in Outpatient Surgeries
    Pascale Carayon, Ann Schoofs Hundt, Carla J. Alvarado, Scott Springman, Amanda Borgsdorf, and Lynn Jenkins.
    • Introduction
    • The organizational context for intervention
    • The collaborative intervention process
    • Implementation of the intervention
    • Data collection
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis
    Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair, Mark Kirschbaum, and Durand E. Burns.
    • Introduction
    • Human factors process analysis
    • Potential sources of error
    • Recommendations
    • Changing the requirements for updating information
    • Outcome
    • Conclusion
    • Acknowledgments
    • References
  • Establishing a Culture of Patient Safety Through a Low-tech Approach to Reducing Medication Errors
    Steven H. Shaha, Linda Brodsky, Michael S. Leonard, Michael A. Cimino, Sandra A. McDougal, Joann M. Pilliod, and Kristen E. Martin.
    • Introduction
    • The journey and process
    • Results
    • Conclusions
    • Acknowledgments
    • References
  • Cost Effectiveness of a Multifaceted Program for Safe Patient Handling
    Kris Siddharthan, Audrey Nelson, Hope Tiesman, and FangFei Chen.
    • Introduction
    • Key elements of the Safe Patient Handling and Movement project
    • Evaluation of the SPHM project
    • Results
    • Limitations and conclusions
    • Acknowledgments
    • References
• Challenges and Lessons Learned
  • Patient Safety Data Sharing and Protection from Legal Discovery
    Steven Suydam, Bryan A. Liang, Storm Anderson, and Matthew B. Weinger.
    • Introduction
    • Is there existing legal protection for patient safety information exchanged across institutional boundaries?
    • Recommendations
    • Conclusions
    • Acknowledgments
    • References
  • Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause?
    John D. Banja.
    • Introduction
    • Part I: Some illustrative cases
    • Part II: Ethical reflections on the cooperation clause
    • Conclusion
    • Acknowledgments
    • References
  • Beyond the Dusty Shelf: Shifting Paradigms and Effecting Change
    Dwight McNeill, Howard Holland, and Kerm Henriksen.
    • Introduction
    • Shifting to a demand paradigm
    • Two models: diffusion and distillation
    • Lessons learned from applying the models
    • Conclusions
    • References
  • From Insight to Implementation: Lessons from a Multi-site Trial of a PDA-based Warfarin Dose Calculator
    Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, and Richard H. White.
    • Introduction
    • Background and methods
    • Results and discussion
    • Conclusions
    • Acknowledgments
    • References
  • Lessons in Safety Climate and Safety Practices from a California Hospital Consortium
    Sara J. Singer, Kelly M. Dunham, Jennie D. Bowen, Jeffrey J. Geppert, David M. Gaba, Kathryn M. McDonald, and Laurence C. Baker.
    • Introduction
    • Measuring safety climate and safety practices
    • Safety climate in hospitals, 2001-2002
    • Conclusion
    • Acknowledgments
    • References
  • Systemwide Deployment of Medical Team Training: Lessons Learned in the Department of Defense
    Heidi B. King, Beth Kohsin, and Mary Salisbury.
    • Introduction
    • Background
    • Implementation process and culture change lessons learned
    • The medical team training blueprint: defining the steps to change
    • Conclusion
    • Acknowledgments
    • References
  • Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation
    Mary V. Wideman, Michael E. Whittler, and Timothy M. Anderson.
    • Introduction
    • Background
    • National and local VHA BCMA collaborative development
    • BCMA implementation challenges
    • Human factors issues
    • Cultural and management issues
    • Acknowledgments
    • References
  • Institutional Review Board Approval of Practice-based Research Network Patient Safety Studies
    Deborah G. Graham, Wilson Pace, Jennifer Kappus, Sherry Holcomb, James M. Galliher, Christine W. Duclos, and Aaron J. Bonham.
    • Introduction and background
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Safety Improvement Initiatives
  • Behind the Scenes: Patient Safety in the Operating Room and Central Materiel Service During Deployments
    Elizabeth A. P. Vane, Edward Drost, Daryl Elder, and Yvonne Heib.
    • Introduction
    • Lessons learned
    • Conclusion
    • Acknowledgments
    • References
  • Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events
    Sandra Ludwick.
    • Introduction
    • Method
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Voluntary Hospital Coalitions to Promote Patient Safety
    Kimberly J. Rask, Dorothy “Vi” Naylor, and Linda Schuessler.
    • Introduction
    • The Partnership for Health and Accountability
    • Key elements of success
    • Conclusions
    • Acknowledgments
    • References
  • Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies
    Laura Bonner, Bradford Felker, Edmund Chaney, Karen Vollen, Karen Berry, Barbara Revay, Barbara Simon, Lial Kofoed, Scott Ober, Linda Worley, John Fotiades, and Scott Sherman.
    • Introduction
    • The Collaborative Care Workgroup approach to improving suicide prevention
    • “Plan”
    • “Do”
    • “Study”
    • “Act”
    • Recommendations
    • Limitations
    • Conclusion
    • Acknowledgments
    • References
  • A New Model of Tracheostomy Care: Closing the Research–Practice Gap
    Joel St. Clair.
    • Introduction
    • Methods
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Peer Reviewers—Volume 3

Suggested citation:

Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implemtation. Vol. 3, Concepts and methodology. AHRQ Publication No. 05-0021-3. 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.