Excerpt

The articles in this volume explore issues of culture and the redesign of organizations and clinical practices to improve patient safety. Within this broad theme are four categories of related articles addressing (1) safety and organizational issues, (2) clinical process improvement, (3) systems redesign, and (4) collaboratives and patient involvement.

Contents

• Preface
• Acknowledgments
• Prologue: Culture and Redesign for Improved Patient Safety
• Safety Culture and Organizational Issues
  • The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs
    Katherine J. Jones, PT, PhD, Anne Skinner, RHIA, Liyan Xu, MS, Junfeng Sun, PhD, and Keith Mueller, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture
    Karen L. Hannah, MBA, Charles P. Schade, MD, MPH, David R. Lomely, BS, Patricia Ruddick, MSN, APRN-BC, and Gail R. Bellamy, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives
    Inga Adams-Pizarro, MHS, ZeAmma Walker, MHSA, PMP, Janet Robinson, RN, CPHQ, PMP, Susan Kelly, PhD, and Margaret Toth, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Measuring Safety Climate in Primary Care Offices
    Gurdev Singh, MscEng, PhD, Ranjit Singh, MA, MB, BChir (Cantab), MBA, Eric J. Thomas, MD, MPH, Reva Fish, PhD, Renee Kee, MS, Elizabeth McLean-Plunkett, MA, Angela Wisniewski, Pharm D, Saburo Okazaki, MD, and Diana Anderson, EdM.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • The PeaceHealth Ambulatory Medication Safety Culture Survey
    Ronald Stock, MD and Eldon R. Mahoney, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care
    Hardeek H. Shah, MPH, ScB, Annie Gjelsvik, PhD, Leo Kobayashi, MD, and Brian Clyne, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Appendix EM Trainee Patient Safety Questionnaire
    • References
  • Is There an Association Between Patient Safety Indicators and Hospital Teaching Status?
    Peter E. Rivard, PhD, Cindy L. Christiansen, PhD, Shibei Zhao, MPH, Anne Elixhauser, PhD, and Amy K. Rosen, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety
    Thomas R. Cunningham, MS and E. Scott Geller, PhD.
    • Introduction
    • Safety-Related OBM Research in Health Care Settings
    • A Disconnect Between OBM and Health Care Management
    • Medical Errors to Target with OBM
    • Conclusion
    • References
  • Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial
    Peter M. Layde, MD, MSc, Linda N. Meurer, MD, MPH, Clare E. Guse, MS, Hongyan Yang, MS, Prakash Laud, PhD, John R. Meurer, MD, MBA, Jean Grube, RN, MBA, PhD, Karen J. Brasel, MD, MPH, and Stephen Hargarten, MD, MPH.
    • Introduction
    • Methods
    • Results
    • Discussion
    • APPENDIX Definitions of intervention targets and priority indicators by ICD-9 codes
    • References
• Clinical Process Improvement
  • Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World
    Stephen M. Borowitz, MD, Linda A. Waggoner-Fountain, MD, Ellen J. Bass, PhD, and Justin M. DeVoge, MS.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Funding
    • Appendix 1 Post-Call Survey
    • References
  • Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care
    Amy J.H. Kind, MD and Maureen A. Smith, MD, MPH, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Challenges to Real-Time Decision Support in Health Care
    Mark Fitzgerald, MB, BS, FACEM, Nathan Farrow, RN, BN (Hons) Adv Nur (Critical Care), Pamela Scicluna, BSc, Angela Murray, RN, Yan Xiao, PhD, and Colin F. Mackenzie, MBChB, FRCA, FCCM.
    • Introduction
    • Implementation Issues
    • Products and Their Evaluation
    • Future Implementation
    • Conclusion
    • References
  • Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process
    Beverly Ann David, PhD, Ana Rodriguez, PharmD, and Stanley W. Marks, MD.
    • Introduction
    • Conclusion
    • References
  • Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes from Paper to Electronic Systems
    Donald K. Baker, PharmD, James M. Hoffman, PharmD, Gregory A. Hale, MD, Sheri L. Spunt, MD, Donald Sanderlin, John H. Rodman, PharmD, and Jerry L. Shenep, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Promoting Best Practice and Safety Through Preprinted Physician Orders
    George Ehringer, MD and Barbara Duffy, RN, LHRM, MPH.
    • Introduction
    • The Essence of Preprinted Physician Orders
    • Engineering: Content
    • Engineering: Format
    • Engineering: Medication Safety
    • Education
    • Enforcement
    • Conclusion
    • Appendix Creating Preprinted Physician Orders for Clinical “best practice” Review
    • References
  • The Impact of Standardized Order Sets on Quality and Financial Outcomes
    David J. Ballard, MD, MSPH, PhD, Gerald Ogola, MS, MPH, Neil S. Fleming, PhD, Dave Heck, MD, Julie Gunderson, RN, BSN, MM, Raaj Mehta, Roger Khetan, MD, and Jeffrey D. Kerr, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • References
  • Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility
    Kathy M. Harney, MS, RN, PNP, Patricia A. Branowicki, MS, RN, CNAA, Margaret McCabe, DNSc, RN, APRN, BC, Kathleen Houlahan, MS, RN, Eileen Sporing, MS, RN, CNAA, and Ellis J. Neufeld, MD, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Creating Safety in the Testing Process in Primary Care Offices
    Nancy C. Elder, MD, MSPH, Timothy R. McEwen, John M. Flach, PhD, and Jennie J. Gallimore, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Role of the External Coach in Advancing Research Translation in Hospital-Based: Performance Improvement
    Nancy Donaldson, RN, DNSc, FAAN, Dana Rutledge, RN, PhD, and Kristin Geiser, PhD.
    • Introduction
    • Project Conceptual Approach and Design
    • Phases of the Coaching Intervention
    • The Reciprocal Roles of the Coach and Linker: Conceptual Foci and Deliverables
    • Outcomes of the Coaching Intervention
    • Discussion and Conclusions
    • References
  • Strategies for Improving Patient Safety in Small Rural Hospitals
    Judith Tupper, MS, CHES, Andrew Coburn, PhD, Stephenie Loux, MS, Ira Moscovice, PhD, Jill Klingner, PhD, and Mary Wakefield, PhD, RN.
    • Introduction
    • Background: The Tennessee Rural Hospital Patient Safety Demonstration
    • The Demonstration
    • Implementation
    • PDA Intervention: Information Technology at the Point of Care
    • Emergency Department Protocols Intervention
    • Conclusion
    • References
• Systems Redesign
  • Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work
    Julie K. Johnson, MSPH, PhD, Stephen H. Miller, MD, MPH, and Sheldon D. Horowitz, MD.
    • Background and Rationale
    • Discussion
    • References
  • Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process
    Kenneth N. Dickerman, ACHA, AIA, FHFI and Paul Barach, BSc, MD, MPH.
    • Introduction
    • Conclusion
    • References
  • Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption
    Heather Woodward Hagg, MS, Jamie Workman-Germann, MS, Mindy Flanagan, PhD, Deanna Suskovich, BA, Susan Schachitti, MBA, Christine Corum, MS, and Bradley N. Doebbeling, MD, MSc.
    • Introduction
    • Methods
    • Results and Discussion
    • Conclusion
    • References
  • Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement
    Jamie N. Deis, MD, Keegan M. Smith, MD, Michael D. Warren, MD, Patricia G. Throop, BSN, CPHQ, Gerald B. Hickson, MD, Barbara J. Joers, MHSA, CHE, and Jayant K Deshpande, MD, MPH.
    • Background
    • Conclusion
    • References
• Collaboratives and Patient Involvement
  • The Patient Safety Education Project: An International Collaboration
    Linda Emanuel, MD, PhD, Merrilyn Walton, PhD, Martin Hatlie, JD, Denys Lau, PhD, Tim Shaw, PhD, Joel Shalowitz, MD, MBA, and John Combes, MD.
    • Introduction
    • Development and Design of the Patient Safety Education Program
    • The PSEP Educational Strategy
    • Conclusion
    • References
  • Harnessing the Potential of Health Care Collaboratives: Lessons from the Keystone ICU Project
    Christine A Goeschel, RN, MPA, MPS and Peter J. Pronovost, MD, PhD.
    • Introduction
    • Conclusion
    • References
  • VHA’s National Falls Collaborative and Prevention Programs
    Erik Stalhandske, MPP, MHSA, Peter Mills, PhD, Pat Quigley, PhD, ARNP, CRRN, FAAN, Julia Neily, MS, MPH, and James P. Bagian, MD, PE.
    • Introduction
    • National Falls Collaborative Breakthrough Project
    • Development and Deployment of the National VHA Falls Toolkit
    • VHA’s National Falls Data Collection Project
    • Results
    • Future Recommendations—Falls Interventions
    • References
  • Hospital Language Services: Quality Improvement and Performance Measures
    Marsha Regenstein, PhD, MCP, Jennifer Huang, MS, Catherine West, MS, RN, Holly Mead, PhD, Jennifer Trott, MPH, and Melissa Stegun, MA.
    • Introduction
    • Conclusion
    • References
  • Using Patient Complaints to Promote Patient Safety
    James W. Pichert, PhD, Gerald Hickson, MD, and Ilene Moore, MD, JD, FCLM.
    • Introduction
    • Summary and Conclusion
    • References
  • From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety
    Diane Valade, MS, A.B. Orlik, Ruth Mohr, RN, MPH, PhD, Vicky Debold, RN, PhD, AkkeNeel Talsma, RN, PhD, Beverley McDonald, and Thomas Simmer, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • The Rural Physician Peer Review Model^©: A Virtual Solution
    Josie R. Williams, MD, Kathy K Mechler, MS, RN, CPHQ, R.B. Akins, John R. Holcomb, MD, Laura K. Gelderd, RN, BSN, R. Kim Clay, Tracy L. Adams, and Janine C. Edwards, PhD.
    • Introduction
    • Innovations
    • Conclusion
    • References
• Peer Reviewers—Volume 2

Suggested citation:

Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.