Friday, December 29, 2006

Managing for Quality

Health care organizations can adapt and use the materials and tools in Managing for Quality to improve quality at many different organizational levels. The following topics are addressed:

  • Problem Solving
  • Focus on the User
  • Build Teams
  • Manage the Process
  • Case Study

Thursday, December 28, 2006

Hospital volume and mortality for mechanical ventilation of medical and surgical patients: A population-based analysis using administrative data

Dale M. Needham, Susan E. Bronskill, Deanna M. Rothwell, William J. Sibbald, Peter J. Pronovost, Andreas Laupacis, Thérèse A. Stukel
Critical Care Medicine. 34(9):2349-2354.

Abstract HTML PDF (235 K)


Volume-outcome relationships: Is it the individual or the team?
Stockwell, D.C., and Slonim, A.D.
Critical Care Medicine 34(9), pp. 2495-2497.

HTML PDF (890 K)

Wednesday, December 27, 2006

Safety by design - Special Issue

Qual Saf Health Care. December 2006;15(suppl 1):i1-i90.

Quality and safety by design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i1-i3.
[Abstract] [Full text] [PDF]

Design of high reliability organizations in health care
J S Carroll and J W Rudolph
Qual Saf Health Care 2006; 15 (Suppl 1): i4-i9.
[Abstract] [Full text] [PDF]

Understanding the complexity of redesigning care around the clinical microsystem
P Barach and J K Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i10-i16.
[Abstract] [Full text] [PDF]

Issues in the design of training for quality and safety
K Henriksen and E Dayton
Qual Saf Health Care 2006; 15 (Suppl 1): i17-i24.
[Abstract] [Full text] [PDF]

Improving patient safety by instructional systems design
J B Battles
Qual Saf Health Care 2006; 15 (Suppl 1): i25-i29.
[Abstract] [Full text] [PDF]

Use of assessment to reinforce patient safety as a habit
R M Galbraith, M C Holtman, and S G Clyman
Qual Saf Health Care 2006; 15 (Suppl 1): i30-i33.
[Abstract] [Full text] [PDF]

Safe design of healthcare facilities
J Reiling
Qual Saf Health Care 2006; 15 (Suppl 1): i34-i40.
[Abstract] [Full text] [PDF]

On the complexity of medical devices and systems
J W Senders
Qual Saf Health Care 2006; 15 (Suppl 1): i41-i43.
[Abstract] [Full text] [PDF]

Mistake proofing: changing designs to reduce error
J R Grout
Qual Saf Health Care 2006; 15 (Suppl 1): i44-i49.
[Abstract] [Full text] [PDF]

Work system design for patient safety: the SEIPS model
P Carayon, A Schoofs Hundt, B-T Karsh, A P Gurses, C J Alvarado, M Smith, and P Flatley Brennan
Qual Saf Health Care 2006; 15 (Suppl 1): i50-i58.
[Abstract] [Full text] [PDF]

A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional
B-T Karsh, R J Holden, S J Alper, and C K L Or
Qual Saf Health Care 2006; 15 (Suppl 1): i59-i65.
[Abstract] [Full text] [PDF]

Violations and migrations in health care: a framework for understanding and management
R Amalberti, C Vincent, Y Auroy, and G de Saint Maurice
Qual Saf Health Care 2006; 15 (Suppl 1): i66-i71.
[Abstract] [Full text] [PDF]

Accidents waiting to happen: the contribution of latent conditions to patient safety
C M Lowe
Qual Saf Health Care 2006; 15 (Suppl 1): i72-i75.
[Abstract] [Full text] [PDF]

Why did that happen? Exploring the proliferation of barely usable software in healthcare systems
C W Johnson
Qual Saf Health Care 2006; 15 (Suppl 1): i76-i81.
[Abstract] [Full text] [PDF]

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification
W B Runciman, J A H Williamson, A Deakin, K A Benveniste, K Bannon, and P D Hibbert
Qual Saf Health Care 2006; 15 (Suppl 1): i82-i90.
[Abstract] [Full text] [PDF]

Tuesday, December 26, 2006

A Systems Approach to Patient-Centered Care

Steven C. Bergeson; John D. Dean
JAMA. 2006;296:2848-2851.


Friday, December 22, 2006

Healthcare Quarterly - Vol. 9 Special Issue

Editorial: Creating Safer Care
G. Ross Baker

Identifying and Reducing Risks

Five Years of Learning from Analysis of Clinical Occurrences in Pediatric Care Using the London Protocol
Catherine M.G. Cronin

Implementing a Good Catch Program in an Integrated Health System
Debbie Barnard, Marilyn Dumkee, Balvir Bains and Brenda Gallivan

The McGill University Health Centre Policy on Sentinel Events: Using a Standardized Framework to Manage Sentinel Events, Facilitate Learning and Improve Patient Safety
Mark Daly

Implementing System Safeguards to Prevent Error-Induced Injury with Opioids (Narcotics)
Margaret Colquhoun, Christine Koczmara and Julie Greenall

Taking Aim at Fall Injury Adverse Events: Best Practices and Organizational Change
Patricia O'Connor, Joann Creager, Sharon Mooney, Andrea Maria Laizner and Judith A. Ritchie

Enhancing Patient Safety through the Management of Clostridium difficile at Toronto East General Hospital
Arladeen Tomiczek, C. Stumpo and James F. Downey

A Multidisciplinary Approach to Reducing Outbreaks and Nosocomial MRSA in a University-Affiliated Hospital
Maryam Salaripour, Pat McKernan, Roslyn Devlin and the Infection Prevention and Control Team

Reporting for Learning and Improvement: The Manitoba and Saskatchewan Experience
Paula Beard and Linda Smyrski

A Framework for Local Accountability for Patient Safety
Rosanne Zimmerman, Emily Christoffersen, Jill Shaver and Teresa Smith

Human Factors and Work Redesign

Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety
Kim Alvarado, Ruth Lee, Emily Christoffersen, Nancy Fram, Sheryl Boblin, Nancy Poole, Janie Lucas and Shirley Forsyth

Is Your Patient Ready for Transport? Developing an ICU Patient Transport Decision Scorecard
Rosmin Esmail, Deborah Banack, Cheryl Cummings, Judy Duffett-Martin, Jonas Shultz, Teresa Thurber, Karen Rimmer and Terrance Hulme

The Role of Typography in Differentiating Look-Alike/Sound-Alike Drug Names
Sandra Gabriele

Involving Patients and Families

Patient Safety in a Pediatric Centre: Partnering with Families
Bonnie Fleming-Carroll, Anne Matlow, Siobhan Dooley, Valerie McDonald, Kimberley Meighan and Kim Streitenberger

"Your Health Care - Be Involved": The Evaluation of a Provincial Patient Safety Tips Initiative
Sudha Kutty and Sarena Weil

Using Information to Improve Safety

Cancer Care Ontario's Computerized Physician Order Entry System: A Province-wide Patient Safety Innovation
Anna Greenberg, Sarah Kramer, Vickie Welch, Emily O'Sullivan and Stephen Hall

Predicting Changes in Workflow Resulting from Healthcare Information Systems: Ensuring the Safety of Healthcare
Andre Kushniruk, Elizabeth Borycki, Shige Kuwata and Joseph Kannry

Frequency and Type of Medication Discrepancies in One Tertiary Care Hospital
Jennifer Turple, Neil J. MacKinnon and Bryan Davis

Identifying Patient Safety Risks in Non-Acute Care Settings

Broadening the Patient Safety Agenda to Include Home Care Services
Ariella Lang, Nancy Edwards, Carolyn Hoffman, Judith Shamian, Kathleen Benjamin and Marguerite Rowe

Adverse Events among Winnipeg Home Care Clients
Keir G. Johnson

Exploration of Patient Safety Phenomena in Rehabilitation and Complex Continuing Care
Carol Fancott, Karima Velji, Elaine Aimone and Lynne Sinclair

Thursday, December 21, 2006

Identification of surgical complications and deaths

an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program
Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA.

J Am Coll Surg. 2006 Nov;203(5):618-24.

Wednesday, December 20, 2006

Adverse Events Detected by Clinical Surveillance on an Obstetric Service

Alan J. Forster, Irene Fung, Sharon Caughey, Lawrence Oppenheimer, Cathy Beach, Kaveh G. Shojania, Carl van Walraven Obstet Gynecol 2006 108: 1073-1083.
[Abstract] [Full Text] [PDF]


Patient Safety in Obstetrics and Gynecology: An Agenda for the Future
Mark D. Pearlman
Obstet Gynecol 2006 108: 1266-1271.
[Abstract] [Full Text] [PDF]


Patient Safety in Obstetrics and Gynecology: The Call to Arms
William A. Grobman
Obstet Gynecol 2006 108: 1058-1059.

[Full Text] [PDF]

Tuesday, December 19, 2006

The American Surgeon - Vol. 72, No. 11. (November 2006)

A Three-Decade Perspective on Anesthesia Safety pp. 985-989 Lanier, William L.

Early Efforts with Quality at Centers for Medicare & Medicaid Services and Judicious Use of Its Powers as a Payor pp. 990-993 Grissom, Thomas L.

Safety, Quality, and the National Surgical Quality Improvement Program pp. 994-998 Khuri, Shukri F.

Surgical Quality Programs in the Veterans Health Administration pp. 999-1004(6) Author: Depalma, Ralph G

American College of Surgeons Remains Committed to Patient Safety pp. 1005-1009(5) Authors: Russell, Thomas R.; Jones, R. Scott

The Surgical Infection Prevention and Surgical Care Improvement Projects: Promises and Pitfalls pp. 1010-1016(7) Author: Bratzler, Dale w.

The Evolution of Guidelines Toward Standards of Practice pp. 1017-1020(4) Author: Polk, Hiram C

PANEL 1 pp. 1021-1030(10) Authors: Polk, Hiram C.; Bratzler, Dale; Depalma, Ralph G; Flum, David R; Grissom, Thomas L; Jones, R. Scott; Khuri, Shukri F; Lanier, William L; Loeb, Thomas M; Pugliese, Gina; Scutchfield, F. Douglas

The Hazards of Using Administrative Data to Measure Surgical Quality pp. 1031-1037(7) Authors: Fry, Donald E; Pine, Michael B; Jordan, Harmon S; Hoaglin, David C; Jones, Barbara; Meimban, Roger

The Volume-Outcome Debate Revisited pp. 1038-1042(5) Author: Finlayson, Samuel R.G

The Challenge of Small Numbers to the Contemporary Excellence of Elective Specialty Surgery pp. 1043-1045(3) Author: Polk, Hiram C

The Holy Grail of Surgical Quality Improvement: Process Measures or Risk-Adjusted Outcomes? pp. 1046-1050(5) Author: Rogers, Selwyn O

Quality and Safety Performance in Teaching Hospitals pp. 1051-1054(4) Author: Knapp, Richard M

Does Outcomes Research Impact Quality? Examples from Bariatric Surgery pp. 1055-1060(6) Author: Hutter, Matthew M.

PANEL 2 pp. 1061-1069(9) Authors: Flum, David R.; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E; Hutter, Matthew M; Khuri, Shukri F; Knapp, Richard M; Rogers, Selwyn O; Russell, Thomas R; Seidenfeld, John J

An Eight-Year Analysis of Surgical Morbidity and Mortality: Data and Solutions pp. 1070-1081(12) Authors: Goldfarb, Michael A; Baker, Thomas

The Challenge of Changing Roles and Improving Surgical Care Now: Crew Resource Management Approach pp. 1082-1087(6) Authors: James, Mcgreevy; Otten, Tyler; Poggi, Michael; Robinson, Christopher; Castaneda, David; Wade, Patrick

How a System for Reporting Medical Errors Can and Cannot Improve Patient Safety pp. 1088-1091(4) Author: Clarke, John R

Maintenance of Certification: American Board of Surgery Goals pp. 1092-1096(5) Author: Lewis, Frank R

Simulation: A Strategy for Success in Quality and Safety in Pay-for-Performance Environments pp. 1097-1101(5) Author: LOYD., GARYE

Making the Operating Room of the Future Safer pp. 1102-1108(7) Authors: Greenberg, Caprice C; Roth, Emilie M; Sheridan, Thomas B; Gandhi, Tejal K; Gustafson, Michael L; Zinner, Michael J; Dierks, Meghan M

Morbidity and Mortality in Vascular Surgery: The Kentucky Experience with a Statewide Database pp. 1109-1111(3) Author: Richardson, J David

The Practicing Surgeon as a Member of the Quality-Safety Team pp. 1112-1114(3) Authors: Vallance, Steven R.; Schell, Robert H.; Robbins, Robert E.

Linking Processes and Outcomes to Improve Surgical Performance: A New Approach to Morbidity and Mortality Peer Review pp. 1115-1119(5) Authors: Pine, Michael; Fry, Donald e.

LUNCHEON DEBATE: Where Is the Captain of the Ship When You Need Her? - System Corrections Are the Right Way to Go pp. 1120-1125(6) Authors: Goldfarb, Michael A.; Flum, David R.

PANEL 3: The Unintended Consequences of Transparency pp. 1126-1132(7) Authors: Willihnganz, Shirley C.; Flum, David R.; Clarke, John R.; Galandiuk, Susan; Knapp, Richard M.; Lewis, John N.; Manassah, Edward E.; Russell, Thomas R.; Taylor, James; Ungar, Laura

PANEL 4—Closing Panel: The Future of Surgical Quality— from Micro to Macro - Would You Rather be Maitre'd (and Set the Table) or be King for a Day? pp. 1133-1148(16) Authors: Flum, David; Bratzler, Dale; Finlayson, Samuel R.G.; Fry, Donald E.; Jones, R. Scott; Lewis, Frank R.; Pine, Michael; Russell, Thomas R.; Seidenfeld, John J.; Vallance, Steven R.

An Invitational Conference on Contemporary Surgical Quality, Safety and Transparency June 5 & 6, 2006 Closing Session—Focal Points pp. 1149-1149(1) Authors: Flum, David R.; Goldfarb, Michael A.; Polk, Hiram C.

Monday, December 18, 2006

Data mining and clinical data repositories: Insights from a 667,000 patient data set

Irene M. Mullins, Mir S. Siadaty, Jason Lyman, Ken Scully, Carleton T. Garrett, W. Greg Miller, Rudy Muller, Barry Robson, Chid Apte, Sholom Weiss et al.
Comput Biol Med. 2006 Dec;36(12):1351-77.

Abstract Full Text + Links PDF (272 K) free PDF

Friday, December 15, 2006

AHRQ - Summary Statement on Comparative Hospital Public Reporting

"The Agency for Healthcare Research and Quality (AHRQ) applauds public reporting of hospital quality performance data and views public reporting as one important strategy to advance the quality improvement agenda in health care. Evidence shows that publicly reporting performance by specific hospitals is a key element that promotes enhanced patient care. AHRQ continues to be an active participant in such public reporting efforts as the Hospital Quality Alliance, the Ambulatory Care Quality Alliance and the National Quality Forum (NQF). In fact, AHRQ is submitting the Quality Indicators (QIs) to NQF to undergo the formal consensus process for endorsement for public reporting in the spring of 2006 ..."

read the full statement (pdf)

Thursday, December 14, 2006

IHI - 5 Million Lives Campaign

The 5 Million Lives Campaign is a new initiative from the Institute for Healthcare Improvement (IHI) to protect patients from five million incidents of medical harm over the next two years (December 2006 – December 2008).

Web site

Press release

Wednesday, December 13, 2006

Relationship Between Medicare’s Hospital Compare Performance Measures and Mortality Rates

Rachel M. Werner; Eric T. Bradlow
JAMA. 2006;296:2694-2702.



Performance Measures and Clinical Outcomes
Susan D. Horn
JAMA. 2006;296:2731-2732.


Tuesday, December 12, 2006

SEER-Medicare: Calculation of Comorbidity Weights

To assist investigators with the calculation of comorbidity weights, the National Cancer Institute (NCI) provids two SAS macros.

These macros will produce comorbidity weights as developed by Charlson et al (PDF) (J Clin Epidemiol 1993;46:1075-9).

SAS macros

Monday, December 11, 2006

Evaluation of a regional disease management programme for patients with asthma or chronic obstructive pulmonary disease

Lotte Steuten, Bert Vrijhoef, Frits Van Merode, Geert-Jan Wesseling, and Cor Spreeuwenberg
Int J Qual Health Care 2006 18: 429-436;

[Abstract] [Full Text] [PDF]

Friday, December 08, 2006

OECD - Health care: Towards quality performance

The OECD Observer magazine November issue presents an article on Health care systems quality performance: "The performance of health care systems is under scrutiny. The Health Care Quality Indicator Project can help identify what works and what does not. And that will help policy decisions too."

Information on the OECD Health Care Quality Indicators project

Thursday, December 07, 2006

OECD - Health Data 2006 Database


The online version of the fourteenth edition of the OECD Secretariat's electronic data base on health systems has been updated.

The 2006 edition includes new data together with an enhanced software. The standard definitions of variables and the corresponding documentation of country-specific sources and methods have been revised and expanded.

Wednesday, December 06, 2006

Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?

A. Mehrotra, A. M. Epstein and M. B. Rosenthal
Ann Intern Med 2006; 826-833.

Abstract Full Text PDF


Which Type of Medical Group Provides Higher-Quality Care?
L. P. Casalino
Ann Intern Med 2006; 860-861.

Full Text PDF

Tuesday, December 05, 2006

Monday, December 04, 2006

AHRQ - 10 Patient Safety Tips for Hospitals

AHRQ Publication No. 06-P020, May 2006. Rockville, MD,

10 tips for hospitals resulted from findings resulting from studies by the Agency for Healthcare Research and Quality (AHRQ), which has funded more than 100 patient safety projects since 2001.

Press Release

Friday, December 01, 2006