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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Monday, July 31, 2006
A safer place for patients: learning to improve patient safety.
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.
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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
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
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
COMPUTERS IN BIOLOGY AND MEDICINE, 36 (7-8): 669-673; JUL-AUG 2006
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
COMPUTERS IN BIOLOGY AND MEDICINE, 36 (7-8): 789-801; JUL-AUG 2006
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
COMPUTERS IN BIOLOGY AND MEDICINE, 36 (7-8): 748-767; JUL-AUG 2006
Abstract Full Text + Links PDF (799 K)
A pilot ontological model of public health indicators
Surjan, G; Szilagyi, E; Kovats, T
COMPUTERS IN BIOLOGY AND MEDICINE, 36 (7-8): 802-816; JUL-AUG 2006
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
COMPUTERS IN BIOLOGY AND MEDICINE, 36 (7-8): 857-870; JUL-AUG 2006
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
Monday, July 17, 2006
Evaluation of comorbidity indices for inpatient mortality prediction models
Martins, M; Blais, R
JOURNAL OF CLINICAL EPIDEMIOLOGY, 59 (7): 665-669; JUL 2006
Abstract Full Text + Links PDF (120 K)
System Failure versus Personal Accountability — The Case for Clean Hands
D. Goldmann
N Engl J Med 2006 355: 121-123
FREE Full Text PDF
Friday, July 14, 2006
Do Longer Delays for Coronary Artery Bypass Surgery Contribute to Preoperative Mortality in Less Urgent Patients?
Sobolev BG, Levy AR, Kuramoto L, Hayden R, Fitzgerald JM.
Med Care. 2006 Jul;44(7):680-686.
Abstract HTML PDF (354 K)
WebM&M - Key Issues in Developing a Successful Hospital Safety Program
by John Whittington, MD
WebM&M
full text
Thursday, July 13, 2006
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.
Abstract
Tuesday, July 11, 2006
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.
Abstract
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)
Editorial
Whither Quality of Breast Cancer Care?
Silliman, Rebecca A. MD
Medical Care. 44(7):607-608, July 2006.
HTML PDF (88 K)
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.
ABSTRACT FULL TEXT PDF
Editorial
Measuring Hospital Quality: What Physicians Do? How Patients Fare? Or Both?
Ashish K. Jha
JAMA. 2006;296:95-97.
EXTRACT FULL TEXT PDF
Wednesday, July 05, 2006
Administrative Versus Clinical Data for Coronary Artery Bypass Graft Surgery Report Cards: The View From California.
Parker JP, Li Z, Damberg CL, Danielsen B, Carlisle DM.
Med Care. 2006 Jul;44(7):687-695
Abstract HTML PDF (433 K)
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).
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Download the full report
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