Monday, July 31, 2006

A safer place for patients: learning to improve patient safety.

House of Commons Committee on Public Accounts. London, England: The Stationary Office; July 6, 2006. Publication HC 831.

The Committee found that in 2004-05 some 974,000 patient safety incidents and near misses were recorded on NHS trusts' reporting systems. NHS trusts need to bring down the level of avoidable incidents, particularly those leading to serious harm and death, through rigorous implementation of safety alerts and adoption of high impact, evidence based solutions such as those promulgated by the National Patient Safety Agency and the Institute of Innovation and Improvement.

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Friday, July 28, 2006

Geographic Diversity of Low-Volume Hospitals in Total Knee Replacement: Implications For Regionalization Policies.

Losina E, Kessler CL, Wright EA, Creel AH, Barrett JA, Fossel AH, Katz JN.
Med Care. 2006 Jul;44(7):637-645.

Abstract HTML PDF (450 K)

Thursday, July 27, 2006

IOM - Hospital-Based Emergency Care: At the Breaking Point

The Institute of Medicine.s (IOM) Committee on the Future of Emergency Care in the United States Health System was formed in September 2003 to examine the emergency care system in the United States; explore its strengths, limitations, and future challenges; describe a desired vision of the system; and recommend strategies for achieving that vision.

Full Text
PDF Summary

Also of Interest:
Emergency Care for Children: Growing Pains
Emergency Medical Services: At the Crossroads

Wednesday, July 26, 2006

An Autocorrelation-corrected Nonparametric Control Chart Technique for Health Care Quality Applications.

Borckardt, Jeffrey J.; Pelic, Christopher ; Herbert, Joan ; Borckardt, Deza ; Nash, Michael R. ; Cooney, Harriet ; Hardesty, Sue.
Quality Management in Health Care. 15(3):157-162, July/September 2006.

Fulltext PDF (116 K)

Tuesday, July 25, 2006

Health Services Research - Special Issue on Health Care Reliability

August 2006 - Vol. 41 Issue 4p2 Page 1535-1720

Foreword to: Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability. A Special Issue of Health Services Research
James L. Reinertsen, Carolyn Clancy

Organizational Silence and Hidden Threats to Patient Safety
Kerm Henriksen, Elizabeth Dayton

Sensemaking of Patient Safety Risks and Hazards
James B. Battles, Nancy M. Dixon, Robert J. Borotkanics, Barbara Rabin-Fastmen, Harold S. Kaplan

Teamwork as an Essential Component of High-Reliability Organizations
David P. Baker, Rachel Day, Eduardo Salas

Creating High Reliability in Health Care Organizations
Peter J. Pronovost, Sean M. Berenholtz, Christine A. Goeschel, Dale M. Needham, J. Bryan Sexton, David A. Thompson, Lisa H. Lubomski, Jill A. Marsteller, Martin A. Makary, Elizabeth Hunt

Struggling to Invent High-Reliability Organizations in Health Care Settings: Insights from the Field
Nancy M. Dixon, Marjorie Shofer

Enhancing Patient Safety through Organizational Learning: Are Patient Safety Indicators a Step in the Right Direction?
Peter E. Rivard, Amy K. Rosen, John S. Carroll

Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory
Michal Tamuz, Michael I. Harrison

Making Noncatastrophic Health Care Processes Reliable: Learning to Walk before Running in Creating High-Reliability Organizations
Roger K. Resar

Fair and Just Culture, Team Behavior, and Leadership Engagement: The Tools to Achieve High Reliability
Allan S. Frankel, Michael W. Leonard, Charles R. Denham

Achieving a High-Performance Health System: High Reliability Organizations within a Broader Agenda
Anne K. Gauthier, Karen Davis, Stephen C. Schoenbaum

Monday, July 24, 2006

AHRQ - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools.

The manual addresses the following aspects of a fall management program:

  • Chapter 1: Introduction and Program Overview
  • Chapter 2: Fall Response
  • Chapter 3: Data Collection and Analysis Using TRIPS (Tracking Record for Improving Patient Safety)
  • Chapter 4: Long-Term Management
  • Chapter 5: Information and Training for Staff, Primary Care Providers, and Residents and their Families
  • Chapter 6: Environment and Equipment Safety
  • Appendix A: References and Equipment Sources
  • Appendix B: Forms and Training Materials
  • Appendix C: Case Study and Program Examples
  • Appendix D: Falls Engineer Instructions

full text pdf

Friday, July 21, 2006

The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs

C. M. Mangione, R. B. Gerzoff, D. F. Williamson, W. N. Steers, E. A. Kerr, A. F. Brown, B. E. Waitzfelder, D. G. Marrero, R. A. Dudley, C. Kim, W. Herman, T. J. Thompson, M. M. Safford, J. V. Selby and for the TRIAD Study Group*
Ann Intern Med 2006; 107-116.

Abstract Full Text PDF Appendix Figure

What effect does physician "profiling" have on inpatient physician satisfaction and hospital length of stay?

Zemencuk, JK; Hofer, TP; Hayward, RA; Moseley, RH; Saint, S

Abstract Full Text PDF–265K

Thursday, July 20, 2006

Computers in Biology and Medicine - Special Issue on Medical Ontologies

Volume 36, Issues 7-8, Page 669-920 (July-August 2006)

The unexpected high practical value of medical ontologies
Pinciroli, F; Pisanelli, DM
Abstract Full Text + Links PDF (118 K)

Ontologies supporting continuity of care: The case of heart failure
Eccher, C; Purin, B; Pisanelli, DM; Battaglia, M; Apolloni, I; Forti, S
Abstract Full Text + Links PDF (799 K)

Building an ontology of adverse drug reactions for automated signal generation in pharmacovigilance
Henegar, C; Bousquet, C; Louet, ALL; Degoulet, P; Jaulent, MC
Abstract Full Text + Links PDF (799 K)

A pilot ontological model of public health indicators
Surjan, G; Szilagyi, E; Kovats, T
Abstract Full Text + Links PDF (237 K)

Building medical ontologies by terminology extraction from texts: An experiment for the intensive care units
Charlet, J; Bachimont, B; Jaulent, MC
Abstract Full Text + Links PDF (333 K)

Wednesday, July 19, 2006

Ranking hospitals according to acute myocardial infarction mortality: should transfers be included?

Kosseim M, Mayo NE, Scott S, Hanley JA, Brophy J, Gagnon B, Pilote L.
Med Care. 2006 Jul;44(7):664-70.

Abstract HTML PDF (259 K)

Tuesday, July 18, 2006

Thursday, July 13, 2006

Using routine data to define clinical case-mix and compare hospital outcomes in urology.

Mason A, Goldacre MJ, Bettley G, Vale J, Joyce A
BJU International 2006 97:6 1145

html pdf

Development of Measures of the Quality of Emergency Department Care for Children Using a Structured Panel Process

Guttmann, Astrid, Razzaq, Asma, Lindsay, Patty, Zagorski, Brandon, Anderson, Geoffrey M.
Pediatrics 2006 118: 114-123

[Abstract] [Full text] [PDF]

Wednesday, July 12, 2006

Quality Improvement Strategies for Hypertension Management: A Systematic Review

Walsh JM, McDonald KM, Shojania KG, Sundaram V, Nayak S, Lewis R, Owens DK, Goldstein MK.
Med Care. 2006 Jul;44(7):646-657.

Abstract HTML PDF (948 K)

Physician perception of hospital safety and barriers to incident reporting.

Schectman JM, Plews-Ogan ML.
Jt Comm J Qual Patient Safety. 2006;32:337-343.


Tuesday, July 11, 2006

Hospital Volume and the Outcomes of Mechanical Ventilation

Kahn, Jeremy M., Goss, Christopher H., Heagerty, Patrick J., Kramer, Andrew A., O'Brien, Chelsea R., Rubenfeld, Gordon D.
N Engl J Med 2006 355: 41-50

Abstract Full Text PDF

Getting doctors to report medical errors: project DISCLOSE.

King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ.
J Comm J Qual Patient Saf. 2006;32:382-392.


Monday, July 10, 2006

Correlates of Between-Surgeon Variation in Breast Cancer Treatments

Hawley ST, Hofer TP, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Morrow M, Katz SJ.
Med Care. 2006 Jul;44(7):609-616
Abstract HTML PDF (300 K)


Whither Quality of Breast Cancer Care?
Silliman, Rebecca A. MD
Medical Care. 44(7):607-608, July 2006.

Friday, July 07, 2006

IHI - Over 3,000 Hospitals Have Joined the 100,000 Lives Campaign

Institute for Healthcare Improvement (IHI) President and CEO Donald Berwick announces in Atlanta, GA, that hospitals in the 100,000 Lives Campaign have saved an estimated 122,300 lives, exceeding the original goal.

Read the June 14 press release.

Watch a recording of Don Berwick's June 14 plenary speech

Thursday, July 06, 2006

Hospital Quality for Acute Myocardial Infarction: Correlation Among Process Measures and Relationship With Short-term Mortality

Elizabeth H. Bradley; Jeph Herrin; Brian Elbel; Robert L. McNamara; David J. Magid; Brahmajee K. Nallamothu; Yongfei Wang; Sharon-Lise T. Normand; John A. Spertus; Harlan M. Krumholz
JAMA. 2006;296:72-78.



Measuring Hospital Quality: What Physicians Do? How Patients Fare? Or Both?
Ashish K. Jha
JAMA. 2006;296:95-97.


Wednesday, July 05, 2006

Tuesday, July 04, 2006

Monday, July 03, 2006

MCHP - Application of Patient Safety Indicators in Manitoba: A First Look

Given the potential contribution of administrative data to patient safetyrelated policy and practice, the Manitoba Centre for Health Policy (MCHP) set out to develop patient safety indicators using the MCHP Population Health Research Data Repository (Repository).

Indicators were selected and developed based on a review of the literature, the feasibility of using administrative data, and the input of physician Working Group members.
Based on these criteria the following indicators of compromised patient safety were selected for the report: (1) A selection of “Patient Safety Indicators” (PSIs) developed by AHRQ in the U.S., and (2) measures of complications related to laparoscopic cholecystectomy (removal of gallbladder).

Download the summary

Download the full report