The volume starts with papers that look to the future and examine the past with respect to patient safety; however, its overarching theme is assessment. An underlying premise to any volume that focuses on assessment is that the time spent in trying to understand the nature of the problem is well worth the effort. A good understanding of the problem space provides the foundation upon which all subsequent efforts are based. Without adequate assessment, the likelihood that subsequent steps and initiatives will be wide of the mark increases substantially.

Contents

• Preface
• Acknowledgments
• Prologue: Laying the Foundation
• Looking Forward, Benefiting from the Past
  • Envisioning Patient Safety in the Year 2025: Eight Perspectives
    Kerm Henriksen, PhD, Caitlin Oppenheimer, MPH, Lucian L Leape, MD, Kirk Hamilton, FAIA, FACHA, MS, David W Bates, MD, MSc, Susan Sheridan, MBA, Mark E Bruley, CCE, David M Gaba, MD, Robert L Wears, MD, MS, and Paul M Schyve, MD.
    • Introduction
    • Simulation
  • What Exactly Is Patient Safety?
    Linda Emanuel, MD, PhD, Don Berwick, MD, MPP, James Conway, MS, John Combes, MD, Martin Hatlie, JD, Lucian Leape, MD, James Reason, PhD, Paul Schyve, MD, Charles Vincent, MPhil, PhD, and Merrilyn Walton, PhD.
    • Introduction
    • Intellectual History of Patient Safety
    • Defining Patient Safety
    • A Patient Safety Model of Health Care
    • Conclusion
    • References
• Reporting Systems
  • Improving the Value of Patient Safety Reporting Systems
    Peter J Pronovost, MD, PhD, Laura L Morlock, PhD, J Bryan Sexton, PhD, Marlene R Miller, MD, MSc, Christine G Holzmueller, BLA, David A Thompson, DNSc, MS, Lisa H Lubomski, PhD, and Albert W Wu, MD, MPH.
    • Introduction
    • Future Directions
    • References
  • The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX^® Data
    Katherine J Jones, PT, PhD, Gary L Cochran, PharmD, SM, Liyan Xu, MS, Anne Skinner, RHIA, Alana Knudson, PhD, and Rodney W Hicks, PhD, ARNP.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Proactive Postmarketing Surveillance: Overview and Lessons Learned from Medication Safety Research in the Veterans Health Administration
    Robert R Campbell, JD, MPH, PhD, Andrea M Spehar, DVM, MPH, JD, and Dustin D French, PhD.
    • Introduction
    • Current U.S. Initiatives
    • Lessons Learned from Center Medication Safety Research
    • Conclusion
    • References
  • Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks
    Donna Engleman, BSN, Suzanne Rich, RN, MA, CT, Tina Powell, BA, and Marilyn Flack, MA.
    • Introduction
    • Update on Current MedSun Program
    • LabNet
    • Human Tissue and Cell Subnetwork
    • HeartNet and KidNet
    • Conclusion
    • References
  • Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology
    Martin November, MD, MBA, Lucy Chie, MD, and Saul N Weingart, MD, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Appendix
    • References
  • 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System
    Debora Simmons, RN, MSN, CCRN, CCNS, JoAnn Mick, PhD, RN, MBA, AOCN, CNAA, BC, Krisanne Graves, RN, BSN, CPHQ, and Sharon K Martin, MED, MT (ASCP), SC.
    • Introduction
    • Methods
    • Results
    • Conclusion
    • Appendix 1 Close Call Reporting System Features List
    • Appendix 2 Reporting Tool in Paper form
    • References
  • Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization
    Paul Conlon, PharmD, JD, Rebecca Havlisch, RN, JD, Narendra Kini, MD, MSHA, and Christine Porter, MHSA.
    • Introduction
    • Development of PEERs
    • Replication and Redesign
    • Using PEERs Data
    • Conclusion
    • References
  • Voluntary Adverse Event Reporting in Rural Hospitals
    Charles P Schade, MD, MPH, Patricia Ruddick, MSN, APRN-BC, David R Lomely, BS, and Gail Bellamy, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Supplementary Data
    • References
  • Improving Error Reporting in Ambulatory Pediatrics with a Team Approach
    Daniel R Neuspiel, MD, MPH, Margo Guzman, RN, MSN, and Cari Harewood, MPA.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative
    David R West, PhD, Wilson D Pace, MD, L Miriam Dickinson, PhD, Daniel M Harris, PhD, Deborah S Main, PhD, John M Westfall, MD, Douglas H Fernald, MA, and Elizabeth W Staton, MSTC.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act
    William Riley, PhD, Bryan A Liang, MD, PhD, JD, William Rutherford, MD, and William Hamman, MD, PhD.
    • Introduction
    • Conclusion
    • References
• Taxonomies and Measurement
  • Development of a Comprehensive Medical Error Ontology
    Pallavi Mokkarala, MS, Julie Brixey, RN, PhD, Todd R Johnson, PhD, Vimla L Patel, PhD, Jiajie Zhang, PhD, and James P Turley, RN, PhD.
    • Introduction
    • Conclusions and Future Work
    • References
  • Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy
    John R Clarke, MD, Janet Johnston, MSN, JD, Monica Davis, MSN, MBA, Arthur J Augustine, BS, Matthew Grissinger, RPh, Michael J Gaunt, PharmD, Hedy Cohen, BSN, MS, and William Marella, MBA.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • A System to Describe and Reduce Medical Errors in Primary Care
    Victoria Kaprielian, MD, Truls Østbye, MD, PhD, Samuel Warburton, MD, Devdutta Sangvai, MD, MBA, and Lloyd Michener, MD.
    • Introduction
    • Results
    • Discussion
    • Conclusion
    • Appendix
    • References
  • Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard
    Carolyn E Aydin, PhD, Linda Burnes Bolton, DrPH, RN, FAAN, Nancy Donaldson, DNSc, RN, FAAN, Diane Storer Brown, PhD, RN, FNAHQ, and Ananta Mukerji, MBA.
    • Introduction
    • CalNOC Data Analysis Subsystem
    • Responding to a Changing Health Care Environment
    • Conclusion
    • References
  • Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance
    Paul Hougland, MD, Jonathan Nebeker, MS, MD, Steve Pickard, MBA, Mark Van Tuinen, PhD, Carol Masheter, PhD, Susan Elder, MA, Scott Williams, MD, MPH, and Wu Xu, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • References
  • Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium
    Hude Quan, MD, PhD, Saskia Drösler, MD, Vijaya Sundararajan, MD, MPH, FACP, Eugene Wen, MD, PhD, Bernard Burnand, MD, MPH, Chantal Marie Couris, PhD, Patricia Halfon, MD, Jean-Marie Januel, RN, MPH, Edward Kelley, PhD, Niek Klazinga, MD, PhD, Jean-Christophe Luthi, MD, PhD, Lori Moskal, CHIM, Eric Pradat, MD, Patrick S Romano, MD, MPH, Jennie Shepheard, BS, Lawrence So, MA, Lalitha Sundaresan, MBBS, MPH, Linda Tournay-Lewis, MHS, CHIM, Béatrice Trombert-Paviot, MD, PhD, Greg Webster, MSc, and William A Ghali, MD, MPH.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration
    Stephanie L Shimada, PhD, Maria E Montez-Rath, PhD, Susan A Loveland, MAT, Shibei Zhao, MPH, Nancy R Kressin, PhD, and Amy K Rosen, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
• Challenges and Lessons Learned
  • Patient Safety Learning Pilot: Narratives from the Frontlines
    Shirley E Kellie, MD, MSc, James B Battles, PhD, Nancy M Dixon, PhD, Harold S Kaplan, MD, and Barbara Rabin Fastman, MHA.
    • Introduction
    • Methods
    • Narratives from the Frontlines
    • Study Limitations
    • Conclusion
    • References
  • A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care
    Ranjit Singh, MA, MB, BChir (Cantab.), MBA, Wilson Pace, MD, Ashok Singh, MA, MB, BChir (Cantab), Chester Fox, MD, and Gurdev Singh, MScEng, PhD (Birm)
    • Introduction
    • Discussion
    • References
  • Christiana Care Health System: Safety Mentor Program
    Michele Campbell, RN, MSM, CPHQ, Christine Carrico, RN, MSN, CPHQ, Carol Kerrigan Moore, RN, MS, FNP-BC, and Terri Lynn Palmer, MPA.
    • Introduction
    • Results
    • Discussion
    • Conclusion
    • References
  • News Media and Health Care Providers at the Crossroads of Medical Adverse Events
    Pamela Whitten, PhD, Mohan J Dutta, PhD, Serena Carpenter, PhD, and Graham D Bodie.
    • Introduction
    • Perceptions of Health Care Providers
    • Results: Health Care Providers
    • Perceptions of the Reporting System
    • Indiana News Media Perceptions
    • Discussion: Putting These Perceptions in Context
    • References
• Risk Assessment
  • Risk-Based Patient Safety Metrics
    Matthew C Scanlon, MD, Ben-Tzion Karsh, PhD, and Kelly A Saran, MS, RN.
    • Introduction
    • Error-Based Patient Safety Metrics
    • Injury-Based Patient Safety Metrics
    • Hazard- or Risk-Based Patient Safety Metrics
    • Additional Applications of Risk-Based Patient Safety Metrics
    • Conclusion
    • References
  • Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning
    Donna M Woods, EdM, PhD, Jane L Holl, MD, MPH, Jon Young, MS, Sally Reynolds, MD, Ellen Schwalenstocker, PhD, Robert Wears, MD, Julia Barnathan, MS, and Laura Amsden, MSW, MPH.
    • Background
    • Conclusion
    • References
  • A Model of Care Delivery to Reduce Falls in a Major Cancer Center
    Nancy E Kline, PhD, RN, CPNP, FAAN, Bridgette Thom, MS, Wayne Quashie, MPH, RN, Patricia Brosnan, MPH, RN, and Mary Dowling, MSN, RN.
    • Introduction
    • Results
    • Discussion
    • Conclusion
    • References
  • Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care
    Mary L Hook, PhD, APRN, BC, Elizabeth C Devine, PhD, RN, FAAN, and Norma M Lang, PhD, RN, FAAN, FRCN.
    • Introduction
    • Applying the Process to Fall Prevention in Acute Care
    • Conclusion
    • References
  • Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings
    Robyn RM Gershon, MT, MHS, DrPH, Monika Pogorzelska, MPH, Kristine A Qureshi, RN, DNSc, Patricia W Stone, PhD, Allison N Canton, BA, Stephanie M Samar, BA, Leah J Westra, BA, Marc R Damsky, MPH, and Martin Sherman, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
• Cause Analysis
  • The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures
    Lawrence L Faltz, MD, FACP, John N Morley, MD, FACP, Ellen Flink, MBA, and Peg DeHont Dameron, BSN.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • References
  • Department of Veterans Affairs Emergency Airway Management Initiative
    Erik J Stalhandske, MPP, MHSA, Michael J Bishop, MD, and James P Bagian, MD, PE.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • References
  • Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities
    Patricia Ruddick, RN, MSN, Karen Hannah, MBA, Charles P Schade, MD, Gail Bellamy, PhD, John Brehm, MD, and David Lomely, BA.
    • Introduction
    • Background (Pilot Study)
    • Methods
    • Results
    • Discussion
    • Conclusions
    • References
  • Common Cause Analysis: Focus on Institutional Change
    Anne Marie Browne, MSN, RN, Robert Mullen, PharmD, Jeanette Teets, MSN, CRNP, RN, Annette Bollig, MSN, RN, and James Steven, MD, SM.
    • Introduction
    • Methods
    • Discussion
    • References
• Peer Reviewers—Volume 1

Suggested citation:

Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 1. Assessment. AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.