The Challenges to Transparency in Reporting Medical Errors

Paterick, Zachary R.; Paterick, Barbara B.; Waterhouse, Blake E.; Paterick, Timothy E.

Journal of Patient Safety. 5(4):205-209, December 2009.

abstract

Editorial

Where We Are a Decade After To Err is Human

Clancy, Carolyn M.

Journal of Patient Safety. 5(4):199-200, December 2009

Chasing Zero: Can Reality Meet the Rhetoric?

Denham, Charles R.; Angood, Peter; Berwick, Don; Binder, Leah; Clancy, Carolyn M.; Corrigan, Janet M.; Hunt, David

Journal of Patient Safety. 5(4):216-222, December 2009.

abstract

The Chasing Zero Department: Making Idealized Design a Reality

Denham, Charles R.; Angood, Peter; Berwick, Don; Binder, Leah; Clancy, Carolyn M.; Corrigan, Janet M.; Hunt, David

Journal of Patient Safety. 5(4):210-215, December 2009.

abstract

Development of a validation algorithm for 'present on admission' flagging.

Jackson TJ, Michel JL, Roberts R, Shepheard J, Cheng D, Rust J, Perry C.

BMC Med Inform Decis Mak. 2009 Dec 1;9(1):48.

Pubmed

Transforming Care at the Bedside (TCAB)

Nurses Transforming Care.

Am J Nurs. 2009;109(Suppl 11):3-80, C3.

Free supplement

The Transforming Care at the Bedside (TCAB) Toolkit

The Transforming the Care at the Bedside initiative

Sequential monitoring of hospital adverse events when control charts fail: the example of fall injuries in hospitals

A Barker, A Morton, M Gatton, E Tong, A Clements

Qual Saf Health Care 2009;18:473-477

[Abstract]

[Full text]

[PDF]

Alternative Pay-for-Performance Scoring Methods: Implications for Quality Improvement and Patient Outcomes

Glickman, Seth W.; Boulding, William; Roos, Jason M. T.; Staelin, Richard; Peterson, Eric D.; Schulman, Kevin A.
Medical Care. 47(10):1062-1068, October 2009.
doi: 10.1097/MLR.0b013e3181a7e54c
Pubmed

Diagnostic Error in Medicine.

Special supplement with 12 articles from a 2008 conference on Diagnostic Error.
Berner ES, Graber ML
Adv Health Sci Educ Theory Pract. 2009;14(suppl 1):1-112.
Table of contents

Effects of evidence-based clinical practice guidelines on quality of care: a systematic review

M Lugtenberg, J S Burgers, and G P Westert
Qual Saf Health Care 2009; 18: 385-392.
[Abstract] [Full Text] [PDF]

Enhancing medication use safety: benefits of learning from your peers

V A Kazandjian, S Ogunbo, K G Wicker, A J Vaida, and F Pipesh
Qual Saf Health Care 2009; 18: 331-335.
[Abstract] [Full Text] [PDF]

SQUIRE after one year

David P Stevens
Qual Saf Health Care 2009; 18: 322.
[Extract] [Full Text] [PDF]

Standards for QUality Improvement Reporting Excellence (SQUIRE) web site link

Errors in Laboratory Medicine and Patient Safety

Clinica Chimica Acta
Volume 404, Issue 1, Pages 1-86 (6 June 2009)
special issue on Laboratory Medicine and Patient Safety
table of contents

Assessing the Appropriateness of Care—Its Time Has Come

Robert H. Brook
JAMA. 2009;302(9):997-998.
EXTRACT FULL TEXT PDF

Evolving From Reductionism to Holism: Is There a Future for Systems Medicine?

Howard J. Federoff; Lawrence O. Gostin
JAMA. 2009;302(9):994-996.
EXTRACT FULL TEXT PDF

Data in health data networks

An Electronic Practice-Based Network for Observational Comparative Effectiveness Research
W. D. Pace, M. Cifuentes, R. J. Valuck, E. W. Staton, E. C. Brandt and D. R. West
Ann Intern Med 2009; 338-340.
Abstract Full Text PDF


Design of a National Distributed Health Data Network
J. C. Maro, R. Platt, J. H. Holmes, B. L. Strom, S. Hennessy, R. Lazarus and J. S. Brown
Ann Intern Med 2009; 341-344.
Abstract Full Text PDF


Editorial

Toward Reuse of Clinical Data for Research and Quality Improvement: The End of the Beginning?
M. G. Weiner and P. J. Embi
Ann Intern Med 2009; 359-360.
Full Text PDF

Pediatric Quality

Pediatric Clinics of North America
Volume 56, Issue 4, Pages 731-1034 (August 2009)
special issyue on Pediatric Quality
table of contents

Hospitalists and the quality of care in hospitals.

López L, Hicks LS, Cohen AP, McKean S, Weissman JS.
Arch Intern Med. 2009 Aug 10;169(15):1389-94.
PubMed

Editorial
Do hospitalists improve quality?
Centor RM, Taylor BB.
Arch Intern Med. 2009 Aug 10;169(15):1351-2.
PubMed

Clinical handover: critical communications

a special supplement from The Medical Journal of Australia on Clinical handover
Med J Aus 2009; 190 (11 Suppl): S105-S160. www.mja.com.au/public/issues/190_11_010609/contents_suppl_010609.html

The Contribution of Longitudinal Comorbidity Measurements to Survival Analysis

Wang, C Y.; Baldwin, Laura-Mae; Saver, Barry G.; Dobie, Sharon A.; Green, Pamela K.; Cai, Yong; Klabunde, Carrie N.
Medical Care. 47(7):813-821, July 2009.
Pubmed

Developing quality indicators for elderly surgical patients.

McGory ML, Kao KK, Shekelle PG, Rubenstein LZ, Leonardi MJ, Parikh JA, Fink A, Ko CY.
Ann Surg. 2009 Aug;250(2):338-47.
PubMed

Relationship Between Discharge Practices and Intensive Care Unit In-Hospital Mortality Performance: Evidence of a Discharge Bias

Vasilevskis, Eduard E.; Kuzniewicz, Michael W.; Dean, Mitzi L.; Clay, Ted; Vittinghoff, Eric; Rennie, Deborah J.; Dudley, R Adams
Medical Care. 47(7):803-812, July 2009.
Pubmed

The Structure of Critical Care Transfer Networks

Iwashyna, Theodore J.; Christie, Jason D.; Moody, James; Kahn, Jeremy M.; Asch, David A.
Medical Care. 47(7):787-793, July 2009
Pubmed

Geographical Distribution of Surgical Capabilities and Disparities in the Use of High-Volume Providers: The Case of Coronary Artery Bypass Graft

Bao, Yuhua; Kamble, Shital
Medical Care. 47(7):794-802, July 2009.
Pubmed

Setting Priorities for Patient Safety: Ethics, Accountability, and Public Engagement

Peter J. Pronovost; Ruth R. Faden
JAMA. 2009;302(8):890-891.
EXTRACT FULL TEXT PDF

Medication Errors.

Brit J Clin Pharmacol. 2009;67:589-695.
special issue on medication errors
www3.interscience.wiley.com/journal/122467149/issue

Effects of Pay for Performance on the Quality of Primary Care in England

Campbell, Stephen M., Reeves, David, Kontopantelis, Evangelos, Sibbald, Bonnie, Roland, Martin
N Engl J Med 2009 361: 368-378
Abstract FREE Full Text PDF Supplementary Material

The Shifting Mission of Health Care Delivery Organizations

Bohmer, Richard M.J., Lee, Thomas H.
N Engl J Med 2009 361: 551-553
Extract FREE Full Text PDF

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD.

Ann Surg. 2009 July 29; [Epub ahead of print].

link

Associations of Physician Volume and Weekend Admissions With Ischemic Stroke Outcome in Taiwan: A Nationwide Population-Based Study

Tung, Yu-Chi; Chang, Guann-Ming; Chen, Yi-Hau
Medical Care. 47(9):1018-1025, September 2009.
link

Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported

Wallace LM, Spurgeon P, Adams S, Earll L, Bayley
J. Qual Saf Health Care. 2009;18:288-291.
Pubmed

Setting Priorities for Patient Safety: Ethics, Accountability, and Public Engagement

Peter J. Pronovost; Ruth R. Faden
JAMA. 2009;302(8):890-891.
EXTRACT FULL TEXT PDF

Improving Chronic Illness Care: A Longitudinal Cohort Analysis of Large Physician Organizations

Shortell, Stephen M.; Gillies, Robin; Siddique, Juned; Casalino, Lawrence P.; Rittenhouse, Diane; Robinson, James C.; McCurdy, Rodney K.
Medical Care. 47(9):932-939, September 2009.
link

Editorial
A Decade With the Chronic Care Model: Some Progress and Opportunity for More
Jackson, George L.; Weinberger, Morris
Medical Care. 47(9):929-931, September 2009.
link

What’s the difference between a hospital and a bottling factory?

A Morton, J Cornwell
BMJ 2009;339:b2727
[Extract] [Full text]

Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ.
Lancet. 2009;374:444-445.
Preview Full Text PDF


Peter Pronovost: champion of checklists in critical care
Jeremy Laurance
Lancet. 2009;374:443
Preview Full Text PDF


see also
The checklist.
Gawande A.
The New Yorker. December 10, 2007;83:86-95.
full text

Heart Failure Performance Measures and Outcomes: Real or Illusory GainsGregg C. Fonarow;

Eric D. Peterson
JAMA. 2009;302(7):792-794.
EXTRACT FULL TEXT PDF

Registries for Robust Evidence

Nancy A. Dreyer; Sarah Garner
JAMA. 2009;302(7):790-791.
EXTRACT FULL TEXT PDF

Data-Based Risk Calculators Becoming More Sophisticated—and More Popular

Mike Mitka
JAMA. 2009;302(7):730-731.
EXTRACT FULL TEXT PDF

Doctors condemn NHS comparison website

Jo Carlowe
BMJ 2009;339:b3341, doi: 10.1136/bmj.b3341
http://www.bmj.com/cgi/content/extract/339/aug14_2/b3341?papetoc

see also:
www.nhs.uk/choiceintheNHS/Toolsandresources/Pages/helpingyouchoose.aspx

Evolution of the surgeon-volume, patient-outcome relationship.

Boudourakis LD, Wang TS, Roman SA, Desai R, Sosa JA.
Ann Surg. 2009 Jul;250(1):159-65.
PubMed

Application of AHRQ patient safety indicators to English hospital data.

Bottle A, Aylin P.
Qual Saf Health Care. 2009;18:303-308.
Pubmed

Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study

M Zegers, M C de Bruijne, C Wagner, L H F Hoonhout, R Waaijman, M Smits, F A G Hout, L Zwaan, I Christiaans-Dingelhoff, D R M Timmermans, P P Groenewegen, and G van der Wal
Qual Saf Health Care 2009; 18: 297-302.
[Abstract] [Full Text] [PDF]

International Forum on Quality and Safety in Health Care, 2009 Berlin

2009 Forum Video & Speaker Presentations

Video
Keynote plenary sessions and 10 other sessions from this year’s International Forum are now available to view online – View Here

Presentations
To view 2009 speaker presentations - click here

Quality and Safety Education.

Dolansky MA, Singh MK, eds.
Qual Manage Healthc. 2009;18:149-227.

Special issue on patient safety and quality educational initiatives.

Table of contents

Addressing the quality and safety gap

Princeton, NJ: Robert Wood Johnson Foundation; July 2009.

Information
Part I: Free full text (PDF)
Part II: Free full text (PDF)

Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis

Vikram R Comondore, P J Devereaux, Qi Zhou, Samuel B Stone, Jason W Busse, Nikila C Ravindran, Karen E Burns, Ted Haines, Bernadette Stringer, Deborah J Cook, Stephen D Walter, Terrence Sullivan, Otavio Berwanger, Mohit Bhandari, Sarfaraz Banglawala, John N Lavis, Brad Petrisor, Holger Schünemann, Katie Walsh, Neera Bhatnagar, and Gordon H Guyatt
BMJ 2009;339 b2732
[Abstract] [Full text] [PDF]

Performance evaluation of inpatient service in Beijing: a horizontal comparison with risk adjustment based on Diagnosis Related Groups

Weiyan Jian, Yinmin Huang, Mu Hu, and Xiumei Zhang
BMC Health Serv Res. 2009; 9: 72.
Abstract Full Text PDF–462K

Application of patient safety indicators internationally: a pilot study among seven countries

Saskia E. Drösler, Niek S. Klazinga, Patrick S. Romano, Daniel J. Tancredi, Maria A. Gogorcena Aoiz, Moira C. Hewitt, Sarah Scobie, Michael Soop, Eugene Wen, Hude Quan, William A. Ghali, Soeren Mattke, and Edward Kelley
Int J Qual Health Care 2009 21: 272-278;
[Abstract] [Full Text] [PDF]

The incidence of adverse events in Swedish hospitals: a retrospective medical record review study

Michael Soop, Ulla Fryksmark, Max Köster, and Bengt Haglund
Int J Qual Health Care 2009 21: 285-291;
[Abstract] [FREE Full Text] [PDF]

The assessment of adverse events in hospitals in Brazil

Walter Mendes, Mônica Martins, Suely Rozenfeld, and Claudia Travassos
Int J Qual Health Care 2009 21: 279-284;
[Abstract] [Full Text] [PDF]

A comparison of hospital adverse events identified by three widely used detection methods

James M. Naessens, Claudia R. Campbell, Jeanne M. Huddleston, Bjorn P. Berg, John J. Lefante, Arthur R. Williams, and Richard A. Culbertson
Int J Qual Health Care 2009 21: 301-307;
[Abstract] [Full Text] [PDF]

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes

Marleen Smits, Jasper Janssen, Riekie de Vet, Laura Zwaan, Danielle Timmermans, Peter Groenewegen, and Cordula Wagner
Int J Qual Health Care 2009 21: 292-300;
[Abstract] [Full Text] [PDF] [Supplementary Data]

Nursing sensitive quality indicators for nursing home care: international review of literature, policy and practice.

Nakrem S, Vinsnes AG, Harkless GE, Paulsen B, Seim A.
Int J Nurs Stud. 2009 Jun;46(6):848-57.
PubMed

J Nurs Manag - Special Issue: This issue: Risk, Safety and Reliability

Volume 17 Issue 2 , Pages 145 - 266
table of contents

Developing the evidence base for accreditation of healthcare organisations: a call for transparency and innovation

David Greenfield and Jeffrey Braithwaite
Qual Saf Health Care 2009; 18: 162-163.
[Extract] [Full Text] [PDF]

Reducing health care hazards: lessons from the commercial aviation safety team.

Pronovost PJ, Goeschel CA, Olsen KL, Pham JC, Miller MR, Berenholtz SM, Sexton JB, Marsteller JA, Morlock LL, Wu AW, Loeb JM, Clancy CM.
Health Aff (Millwood). 2009 May-Jun;28(3):w479-89.
PubMed

Verbal orders and patient safety

Commentaries:
Getting your point across: verbal orders and patient safety
Karyn D Baum
Qual Saf Health Care 2009; 18: 164.
[Extract] [Full Text] [PDF]

Original research:

Are verbal orders a threat to patient safety?
D S Wakefield and B J Wakefield
Qual Saf Health Care 2009; 18: 165-168.
[Abstract] [Full Text] [PDF]

An exploratory study measuring verbal order content and context
D S Wakefield, J Brokel, M M Ward, T Schwichtenberg, D Groath, M Kolb, J W Davis, and D Crandall
Qual Saf Health Care 2009; 18: 169-173.
[Abstract] [Full Text] [PDF]

Getting to the heart of high-quality care

Editorial
The Lancet Volume 374, Issue 9688, Page 427
Full Text PDF

Omitted and unjustified medications in the discharge summary

A Perren, M Previsdomini, B Cerutti, D Soldini, D Donghi, and C Marone
Qual Saf Health Care 2009; 18: 205-208.
[Abstract] [Full Text] [PDF]

Using routine intelligence to target inspection of healthcare providers in England

M Bardsley, D J Spiegelhalter, I Blunt, X Chitnis, A Roberts, and S Bharania
Qual Saf Health Care 2009; 18: 189-194.
[Abstract] [Full Text] [PDF]

New World of Patient Safety: 23rd Annual Samuel Jason Mixter Lecture

Lucian L. Leape
Arch Surg. 2009;144(5):394-398.
EXTRACT FULL TEXT PDF

Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances?

Davina Allen, Elizabeth Gillen, Laura Rixson

International Journal of Evidence-Based Healthcare Volume 7 Issue 2 (p 61-74)

Abstract References Full Text: HTML, PDF (Size: 117K)

Editorial

Standardising care using integrated care pathways: if they seem like a solution, did we ask the right questions?
Jo Rycroft-Malone, Debra Bick
International Journal of Evidence-Based Healthcare Volume 7 Issue 2 (p 59-60)
Abstract References Full Text: HTML, PDF (Size: 38K)

AHRQ - National Healthcare Quality Report 2008.

Agency for Healthcare Research and Quality
2009. AHRQ Publication No. 09-0001.
Free full text (PDF)

Risk, Safety and Reliability Special Issue.

editors: David Newbold and Moira Attree
J Nurs Manag. 2009;17:145-266.
www3.interscience.wiley.com/journal/122314424/issue

What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist

Donald M. Berwick
Health Affairs, July/August 2009; 28(4): w555-w565.
[ Abstract ] [ Full Text ] [ PDF ]

A next act for patient safety.

Viola AF, Kallem C, Bronnert J.
J AHIMA. 2009;80:30-35.
Pubmed

Shop for Quality or Volume? Volume, Quality, and Outcomes of CoronaryArtery Bypass Surgery

Andrew D. Auerbach, Joan F. Hilton, Judith Maselli, Penelope S. Pekow,Michael B. Rothberg, and Peter K. Lindenauer
Ann Intern Med 2009;150 696-704
Abstract Full Text PDF


editorial

Quality Wrapped in Volume Inside a Hospital
Peter B. Bach
Ann Intern Med 2009;150 729-730
Full Text PDF

Quality and Performance

Health Services Research Volume 44 Issue 3 , (June 2009)

Effects of the Premier Hospital Quality Incentive Demonstration on Medicare Patient Mortality and Cost
Andrew M. Ryan
(p 821-842)
Abstract References Full Text: HTML, PDF (Size: 164K) Supporting information

Managed Care Quality of Care and Plan Choice in New York SCHIP
Hangsheng Liu, Charles E. Phelps, Peter J. Veazie, Andrew W. Dick, Jonathan D. Klein, Laura P. Shone, Katia Noyes, Peter G. Szilagyi
(p 843-861)
Abstract References Full Text: HTML, PDF (Size: 129K) Supporting information

The Relationship between Hospital Volume and Mortality in Mechanical Ventilation: An Instrumental Variable Analysis
Jeremy M. Kahn, Thomas R. Ten Have, Theodore J. Iwashyna
(p 862-879)
Abstract References Full Text: HTML, PDF (Size: 117K) Supporting information

Organizational and Market Influences on Physician Performance on Patient Experience Measures
Hector P. Rodriguez, Ted von Glahn, William H. Rogers, Dana Gelb Safran
(p 880-901)
Abstract References Full Text: HTML, PDF (Size: 135K) Supporting information

Retention, Learning by Doing, and Performance in Emergency Medical Services
Guy David, Tanguy Brachet
(p 902-925)
Abstract References Full Text: HTML, PDF (Size: 187K) Supporting information

Health Care Efficiency

Volume 44 Issue 3 , (June 2009)

A Systematic Review of Health Care Efficiency Measures
Peter S. Hussey, Han de Vries, John Romley, Margaret C. Wang, Susan S. Chen, Paul G. Shekelle, Elizabeth A. McGlynn
(p 784-805)
Abstract References Full Text: HTML, PDF (Size: 186K) Supporting information

Commentary: A Systematic Review of Health Care Efficiency Measures
Leah F. Binder, Barbara Rudolph
(p 806-811)
Abstract References Full Text: HTML, PDF (Size: 48K)

Commentary: Slack Resources in Health Care Organizations—Fat to Be Trimmed or Muscle to Be Exercised?
Jacqueline Zinn, Ann Barry Flood
(p 812-820)
Abstract References Full Text: HTML, PDF (Size: 64K)

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, Lasky RE, Sexton JB, Thomas EJ.
Am J Surg. 2009 May;197(5):678-85.
PubMed

Quality Improvement: Science and Action

Henry H. Ting, Kaveh G. Shojania, Victor M. Montori, and Elizabeth H. Bradley Circulation. 2009;119:1962-1974,
Extract Full Text PDF

Alternative comorbidity adjustors for the Medicare inpatient psychiatric facility PPS.

Drozd EM, Maier J, Hales JF, Thomas FG.
Health Care Financ Rev. 2008 Winter;30(2):67-82.
PubMed

Medicare risk adjustment for the frail elderly.

Kautter J, Ingber M, Pope GC.
Health Care Financ Rev. 2008 Winter;30(2):83-93.
PubMed

Quality and safety indicators in anesthesia: a systematic review.

Haller G, Stoelwinder J, Myles PS, McNeil J.
Anesthesiology. 2009 May;110(5):1158-75.
PubMed

Global priorities for patient safety research

David W Bates, Itziar Larizgoitia, Nittita Prasopa-Plaizier, Ashish K Jha, on behalf of the Research Priority Setting Working Group of the WHO World Alliance for Patient Safety
BMJ 2009;338:b1775, doi: 10.1136/bmj.b1775
link

Medication errors in critical care: risk factors, prevention and disclosure

Eric Camiré, Eric Moyen, and Henry Thomas Stelfox
CMAJ 2009 180: 936-943.
[Full Text] [PDF] [Figures Only] [Online Appendices]

Health care process modelling: which method when?

Gyuchan Thomas Jun, James Ward, Zoe Morris, and John Clarkson
Int J Qual Health Care 2009 21: 214-224;
[Abstract] [Full Text] [PDF]

Validation of a tool assessing appropriateness of hospital days in rehabilitation centres Int J Qual

Romain Guilé, Christophe Leux, Cécile Paillé, Pierre Lombrail, and Leila Moret
Health Care 2009 21: 198-205;
[Abstract] [Full Text] [PDF]

Selection of indicators for continuous monitoring of patient safety: recommendations of the project ‘safety improvement for patients in Europe’

Solvejg Kristensen, Jan Mainz, and Paul Bartels
Int J Qual Health Care 2009 21: 169-175;
[Abstract] [Full Text] [PDF]

Pseudoinnovation: the development and spread of healthcare quality improvement methodologies

Kieran Walshe
Int J Qual Health Care 2009 21: 153-159;
[Abstract] [Full Text] [PDF] [Supplementary Data]

AHRQ - Quality Indicator Version 4.0

The Agency for Healthcare Research and Quality (AHRQ) released the AHRQ Quality Indicators Version 4.0 for the Prevention Quality Indicators (PQI), Inpatient Quality Indicators (IQI), Patient Safety Indicators (PSI), and Pediatric Quality Indicators (PDI) modules.

www.qualityindicators.ahrq.gov/software.htm

Measuring efficiency: the association of hospital costs and quality of care.

Jha AK, Orav EJ, Dobson A, Book RA, Epstein AM.
Health Aff (Millwood). 2009 May-Jun;28(3):897-906.
PubMed

Validation of a modified version of the national nosocomial infections surveillance system risk index for health services research.

Daneman N, Simor AE, Redelmeier DA.
Infect Control Hosp Epidemiol. 2009 Jun;30(6):563-9.
PubMed

Flexible regression models are useful tools to calculate and assess threshold values in the context of minimum provider volumes.

Grouven U, Küchenhoff H, Schräder P, Bender R.
J Clin Epidemiol. 2008 Nov;61(11):1125-31.
PubMed

Quality toolbox: clinical pathways can improve core measure scores.

McCue JD, Beck A, Smothers K.
J Healthc Qual. 2009 Jan-Feb;31(1):43-50.
PubMed

NPSA - Patient Safety Toolkits & E-learning Packages

www.npsa.nhs.uk/nrls/alerts-and-directives/patient-safety-toolkits-e-learning-packages/

This web page from the National Patient Safety Agency (NPSA) provide access to a range of tools and e-learning packages designed to support patient safety education and training.

AHRQ - Getting Safer Care

www.ahrq.gov/consumer/safety.html

This Agency for Healthcare Research and Quality (AHRQ) Web site provides materials to help patients avoid medical errors and receive quality care.

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.

Masica AL, Richter KM, Convery P, Haydar Z.
Proc (Bayl Univ Med Cent). 2009;22:103-111.
Abstract Full Text PDF–146K

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, Baker DW.

J Hosp Med. 2009 Apr;4(4):219-25.
pubmed

Developing a tool for assessing competency in root cause analysis.

Gupta P, Varkey P.
Jt Comm J Qual Patient Saf. 2009 Jan;35(1):36-42.
PubMed

How should continuity of care in primary health care be assessed?

Salisbury C, Sampson F, Ridd M, Montgomery AA.
Br J Gen Pract. 2009 Apr;59(561):e134-41.
PubMed

Using implementation safety indicators for CPOE implementation.

Weir CR, McCarthy CA.
Jt Comm J Qual Patient Saf. 2009 Jan;35(1):21-8.
PubMed

Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration

Christine W. Hartmann, Mark Meterko, Amy K. Rosen, Shibei Zhao, Priti Shokeen, Sara Singer, and David M. Gaba
Med Care Res Rev 2009 66: 320-338.
[Abstract] [PDF]

What Can We Learn From Quality Improvement Research?: A Critical Review of Research Methods

Jeffrey A. Alexander and Larry R. Hearld
Med Care Res Rev 2009 66: 235-271.
[Abstract] [PDF]

NHS Evidence

www.evidence.nhs.uk/



NHS Evidence is a new service, hosted by the UK's National Institute for Health and Clinical Excellence (NICE), launched to provide easy access to evidence base information for health and social care professionals.




see also:

NHS Evidence: better and faster access to information
Gillian C Leng
The Lancet, Volume 373, Issue 9674, Pages 1502 - 1504
Preview Full Text PDF

IHI - Open School

www.ihi.org/IHI/Programs/IHIOpenSchool/

The Institute for Healthcare Improvement (IHI) has created the Open School to teach patient safety and quality improvement; free multimedia training modules are available.

WHO - SAVE LIVES: Clean Your Hands

www.who.int/gpsc/5may/en/index.html

Launched 5 May 2009 by the World Alliance for Patient Safety, the SAVE LIVES: Clean Your Hands initiative aims to support health-care workers to improve hand hygiene and stop the spread of infection.

Closing the safety loop: evaluation of the National Patient Safety Agency's guidance regarding wristband identification of hospital inpatients.

Sevdalis N, Norris B, Ranger C, Bothwell S; Wristband Project Team.
J Eval Clin Pract. 2009 Apr;15(2):311-5.
PubMed

Comorbidity adjustment index for the international classification of diseases, 10th revision.

Ramiarina RA, Ramiarina BL, Almeida RM, Pereira WC.
Rev Saude Publica. 2008 Aug;42(4):590-7.
PubMed

Availability of data for measuring physician quality performance.

Scholle SH, Roski J, Dunn DL, Adams JL, Dugan DP, Pawlson LG, Kerr EA.
Am J Manag Care. 2009 Jan;15(1):67-72.
PubMed

Measuring quality of oral anticoagulation care: extending quality measurement to a new field.

Rose AJ, Berlowitz DR, Frayne SM, Hylek EM.
Jt Comm J Qual Patient Saf. 2009 Mar;35(3):146-55. Review.
PubMed