Relationship of Primary Care Physicians' Patient Caseload With Measurement of Quality and Cost Performance

David J. Nyweide; William B. Weeks; Daniel J. Gottlieb; Lawrence P. Casalino; Elliott S. Fisher
JAMA. 2009;302(22):2444-2450.
ABSTRACT FULL TEXT PDF

Editorial

Measuring Physicians' Quality and Performance: Adrift on Lake Wobegon
Donald M. Berwick
JAMA. 2009;302(22):2485-2486.
EXTRACT FULL TEXT PDF

Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences

McDonald, Ruth, Roland, Martin
Ann Fam Med 2009 7: 121-127
[Abstract] [Full Text] [PDF]

Pressure Ulcer Reduction Toolkit

www.innovations.ahrq.gov/content.aspx?id=2651

TMF Health Quality Institute developed this toolkit to help nursing home staff better prevent, treat, and heal pressure ulcers.

Some of the topics included in the toolkit are:

• Facility-acquired pressure ulcer investigation tool
• Protein-energy malnutrition definition
• Team progress assessment
• Facility-acquired pressure ulcer-free days calendar tool
• Facility-level assessment
• Resident-level assessment
• Quality improvement workbook
• Facility assessment checklist
• Organizational commitment
• Risk assessment
• Development of a plan of care

Clean, Safe Care: Reducing Infections and Saving Lives Strategy

www.clean-safe-care.nhs.uk

The purpose of the site from the UK Department of Health is to provide a hub for information, Tools and News about reducing healthcare associated infections (HCAI) and providing safe, clean, reliable healthcare.

"To Err Is Human" Report Retrospective and the Decade Ahead.

2009 NPSF Congress: Lucian Leape Institute Plenary.

Boston, MA: National Patient Safety Foundation; May 21, 2009.

link

Patient safety at ten: unmistakable progress, troubling gaps.

Wachter RM.

Health Aff (Millwood). 2009 Dec 1

Pubmed

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

The relationship between electronic health record use and quality of care over time.

Zhou L, Soran CS, Jenter CA, Volk LA, Orav EJ, Bates DW, Simon SR.
J Am Med Inform Assoc. 2009 Jul-Aug;16(4):457-64.
PubMed

Quality of Care Provided to Individual Patients in US Hospitals: Results From an Analysis of National Hospital Quality Alliance Data

Vogeli, Christine; Kang, Raymond; Landrum, Mary Beth; Hasnain-Wynia, Romana; Weissman, Joel S.
Medical Care. 47(5):591-599, May 2009
Link

Do Patient Safety Events Increase Readmissions?

Friedman, Bernard; Encinosa, William; Jiang, H Joanna; Mutter, Ryan
Medical Care. 47(5):583-590, May 2009.
Link

Quality of Care and Length of Hospital Stay Among Patients With Stroke

Svendsen, Marie Louise; Ehlers, Lars Holger; Andersen, Grethe; Johnsen, Søren Paaske
Medical Care. 47(5):575-582, May 2009.
Link

The Use of Patient Satisfaction Surveys and Alternative Coding Procedures to Predict Malpractice Risk

Fullam, Francis; Garman, Andrew N.; Johnson, Tricia J.; Hedberg, Eric C.
Medical Care. 47(5):553-559, May 2009.
link

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, Vassault AJ, Mattiuzzi C, Plebani M.
Clin Chem Lab Med. 2009;47:143-153.
Pubmed

Practising safely in the foundation years.

Long S, Neale G, Vincent C.
BMJ. 2009;338:1046.
Extract Full text

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

Bilimoria KY, Kmiecik TE, DaRosa DA, Halverson A, Eskandari MK, Bell RH Jr, Soper NJ, Wayne JD.
Arch Surg. 2009;144:305-311.
Pubmed

Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.

Rebasa P, Mora L, Luna A, Montmany S, Vallverdú H, Navarro S.
World J Surg. 2009 Feb;33(2):191-8.
PubMed

Safety in obstetric critical care.

Scholefield H.
Best Pract Res Clin Obstet Gynaecol. 2008 Oct;22(5):965-82.
pubmed

Quality in primary health care: a multidimensional approach to complexity.

Heath I, Rubinstein A, Stange KC, Driel ML.

BMJ 2009;338:b1242.

[Free Full Text]

Stimulating the Adoption of Health Information Technology

Blumenthal, David
N Engl J Med 2009 360: 1477-1479
Extract FREE Full Text PDF

Measurement of quality and assurance of safety in the critically ill.

Pronovost PJ, Sexton JB, Pharn JC, Goeschel CA, Winters BD, Miller MR.
Clin Chest Med. 2009;30:169-179.
Pubmed

Quality in primary health care: a multidimensional approach to complexity

Iona Heath, Adolfo Rubinstein, Kurt C Stange, and Mieke L van Driel
BMJ 2009;338:b1242, doi: 10.1136/bmj.b1242
Extract Full text

Effect of smoking cessation advice on cardiovascular disease.

Eddy DM, Peskin B, Shcheprov A, Pawlson G, Shih S, Schaaf D.
Am J Med Qual. 2009 May-Jun;24(3):241-9.
PubMed

A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists.

Peterson MC.
Mayo Clin Proc. 2009 Mar;84(3):248-54.
PubMed

Assessing Authority

Drummond Rennie; Iain Chalmers
JAMA. 2009;301(17):1819-1821.
EXTRACT FULL TEXT PDF ORIGINAL ARTICLE

Improving the simple, complicated and complex realities of community-acquired pneumonia

S K Liu, K Homa, J R Butterly, K B Kirkland, and P B Batalden
Qual Saf Health Care 2009; 18: 93-98.
[Abstract] [Full Text] [PDF]

Patient- and procedure-specific risk factors for postoperative complications in peripheral vascular surgery

C P E Lange, A J Ploeg, J-W H P Lardenoye, and P J Breslau
Qual Saf Health Care 2009; 18: 131-136.
[Abstract] [Full Text] [PDF]

The influence of standardisation and task load on team coordination patterns during anaesthesia inductions

E Zala-Mezö, J Wacker, B Künzle, M Brüesch, and G Grote
Qual Saf Health Care 2009; 18: 127-130.
[Abstract] [Full Text] [PDF]

Development and validation of the SURgical PAtient Safety System (SURPASS) checklist

E N de Vries, M W Hollmann, S M Smorenburg, D J Gouma, and M A Boermeester
Qual Saf Health Care 2009; 18: 121-126.
[Abstract] [Full Text] [PDF]

Factors influencing incident reporting in surgical care

S Kreckler, K Catchpole, P McCulloch, and A Handa
Qual Saf Health Care 2009; 18: 116-120.
[Abstract] [Full Text] [PDF]

The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre

A Mishra, K Catchpole, and P McCulloch
Qual Saf Health Care 2009; 18: 104-108. doi:10.1136/qshc.2007.024760
[Abstract] [Full Text] [PDF]

The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre

P McCulloch, A Mishra, A Handa, T Dale, G Hirst, and K Catchpole
Qual Saf Health Care 2009; 18: 109-115.
[Abstract] [Full Text] [PDF] [web only appendices]

Rehospitalizations among Patients in the Medicare Fee-for-Service Program

Jencks, Stephen F., Williams, Mark V., Coleman, Eric A.
N Engl J Med 2009 360: 1418-1428
Abstract Full Text PDF Supplementary Material

Editorial
Revisiting Readmissions -- Changing the Incentives for Shared Accountability
Epstein, Arnold M.
N Engl J Med 2009 360: 1457-1459
Extract Full Text PDF

AHRQ - Triggers and Targeted Injury Detection Systems (TIDS)

www.ahrq.gov/qual/triggers/

AHRQ is developing and supporting the implementation of clinical triggers and targeted injury detection systems (TIDS) to identify patient safety risks and hazards. Clinical triggers are data flags identifying patients who may be at risk of harm or clinical situations that have the potential for harm.

PDF File

NPSA - Publication of Organisation Patient Safety Incident Reports

www.npsa.nhs.uk/nrls/patient-safety-incident-data/organisation-reports/
This section of the National Patient Safety Agency (NPSA) website provides details of patient safety incident reports for individual NHS organisations in England and Wales.

From tasks to processes: the case for changing health information technology to improve health care.

Walker JM, Carayon P.
Health Aff. 2009;28:467-477.
Pubmed

Relationship of safety climate and safety performance in hospitals.

Singer S, Lin S, Falwell A, Gaba D, Baker L.
Health Serv Rev. 2009;44:399-421.
Pubmed

Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults

Gulshan Sharma; Kathlyn E. Fletcher; Dong Zhang; Yong-Fang Kuo; Jean L. Freeman; James S. Goodwin
JAMA. 2009;301(16):1671-1680.
ABSTRACT FULL TEXT PDF JAMA REPORT VIDEO

Pay for Performance: An Overview of the LiteratureStuart

E. Greene and David B. Nash
American Journal of Medical Quality 2009;24 140-163
http://ajm.sagepub.com/cgi/reprint/24/2/140?etoc

Errors in medicine.

Leape LL.
Clin Chim Acta. 2009 Jun;404(1):2-5.
Pubmed

The effect of guidance in the use of routine outcome measures in clinical meetings.

Trauer T, Pedwell G, Gill L.
Aust Health Rev. 2009 Feb;33(1):144-51.
Pubmed

see also:
outcome measurement in mental health
from the Mental Health & Drugs Division of the State Government Department of Health, Victoria, Australia

Use of Electronic Health Records in U.S. Hospitals

Jha, Ashish K., DesRoches, Catherine M., Campbell, Eric G., Donelan, Karen, Rao, Sowmya R., Ferris, Timothy G., Shields, Alexandra, Rosenbaum, Sara, Blumenthal, David
N Engl J Med 2009 360: 1628-1638

Abstract | FREE Full Text | PDF  | Supplementary Material

The Public Health Hazards of Risk Avoidance Associated With Public Reporting of Risk-Adjusted Outcomes in Coronary Intervention

F. Resnic, F. Welt

Journal of the American College of Cardiology, Volume 53, Issue 10, Pages 825-830
Pubmed

Editorial
Public Reporting of Quality Measures What Are We Trying to Accomplish?

R. Califf, E. Peterson

Journal of the American College of Cardiology, Volume 53, Issue 10, Pages 831-833
Pubmed

Creating an Ideal Transition Home for Patients with Heart Failure.

Transforming Care at the Bedside How-to Guide
Nielsen GA, Bartely A, Coleman E, Resar R, Rutherford P, Souw D, Taylor J.
Cambridge, MA: Institute for Healthcare Improvement; 2008.
link

Inpatient suicide: preventing a common sentinel event.

Tishler CL, Reiss NS.

Gen Hosp Psychiatry. 2009;31:103-109.

Pubmed

Learning from defects to enhance morbidity and mortality conferences.

Berenholtz SM, Hartsell TL, Pronovost PJ.
Am J Med Qual. 2009;24:192-195.
Pubmed

Implementation of computerized physician order entry in seven countries.

Aarts J, Koppel R.
Health Aff. 2009;28:404-414.
Pubmed

Health information technology and patient safety: evidence from panel data.

Parente ST, McCullough JS.
Health Aff. 2009;28:357-360.
Pubmed

Laboratory medicine quality indicators: a review of the literature.

Shahangian S, Snyder SR.
Am J Clin Pathol. 2009 Mar;131(3):418-31.
pubmed

Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals

Mohammed A Mohammed, Jonathan J Deeks, Alan Girling, Gavin Rudge, Martin Carmalt, Andrew J Stevens, Richard J Lilford BMJ  2009;338:b780 (Published ) [Abstract] [Full text] [PDF] Editorial Measuring the quality of hospital care John Wright, Kaveh G Shojania  BMJ  2009;338:b569 (Published )  [Extract] [Full text]

Quality in primary health care: a multidimensional approach to complexity.

Heath I, Rubinstein A, Stange KC, Driel ML.  

BMJ 2009;338:b1242. 

[Free Full Text]

NHS - The Care Quality Commission (CQC)

http://www.cqc.org.uk/

The Care Quality Commission (CQC) brings together independent regulation of health, mental health and adult social caren in England. Before 1 April 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. These organisations no longer exist.

The Care Quality Commission (CQC) main activities are:

• Registration of health and social care providers to ensure they are meeting essential common quality standards
  
• Monitoring and inspection of all health and adult social care
  
• Using enforcement powers if standards are not being met
  
• Improving health and social care services 
  
• Reporting the outcomes 
  

Rehospitalizations among Patients in the Medicare Fee-for-Service Program

Jencks, Stephen F., Williams, Mark V., Coleman, Eric A.
N Engl J Med 2009 360: 1418-1428

Abstract | Full Text | PDF  | Supplementary Material

Editorial

Revisiting Readmissions -- Changing the Incentives for Shared Accountability
Epstein, Arnold M.

N Engl J Med 2009 360: 1457-1459

Extract | Full Text | PDF

A New Strategy to Improve Quality: Rewarding Actions Rather Than Measures

Rachel M. Werner; Robert McNutt
JAMA. 2009;301(13):1375-1377.
EXTRACT FULL TEXT PDF

Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality

Leslie P. Kernisan; Sei J. Lee; W. John Boscardin; C. Seth Landefeld; R. Adams Dudley
JAMA. 2009;301(13):1341-1348.
ABSTRACT FULL TEXT PDF

Quality, Transparency, and the US Government

Robert H. Brook
JAMA. 2009;301(13):1377-1378.
EXTRACT FULL TEXT PDF

What is the Perfect General Practice?

www.bristolgpsolutions.nhs.uk/a1.htm

Does public release of performance results improve quality of care? A systematic review

This literature review produced as part of the Quest for Quality and Improved Performance (QQUIP), an initiative of The Health Foundation analyse the public release of performance results.

The report is adapted from a RAND Corporation white paper. 

[PDF]

Quality of Care: Measuring up the NHS

	Nigel Hawkes
	BMJ  2009;338:b703 (Published ) [Extract] [Full text]

Your Doctor's Office or the Internet? Two Paths to Personal Health Records

Tang, Paul C., Lee, Thomas H.
N Engl J Med 2009 360: 1276-1278

Extract | FREE Full Text | PDF

No Small Change for the Health Information Economy

Mandl, Kenneth D., Kohane, Isaac S.
N Engl J Med 2009 360: 1278-1281

Extract | FREE Full Text | PDF

Ownership of Medical Information

Mark A. Hall; Kevin A. Schulman
JAMA. 2009;301(12):1282-1284.
EXTRACT FULL TEXT PDF

Measuring Preventable Harm: Helping Science Keep Pace With Policy

Peter J. Pronovost; Elizabeth Colantuoni
JAMA. 2009;301(12):1273-1275.
EXTRACT FULL TEXT PDF

Health Care Information Technology Vendors' "Hold Harmless" Clause: Implications for Patients and Clinicians

Ross Koppel; David Kreda
JAMA. 2009;301(12):1276-1278.
EXTRACT FULL TEXT PDF

Association of Patient Case-Mix Adjustment, Hospital Process Performance Rankings, and Eligibility for Financial Incentives

Rajendra H. Mehta, Li Liang, Amrita M. Karve, Adrian F. Hernandez, John S. Rumsfeld, Gregg C. Fonarow, and Eric D. Peterson
JAMA. 2008;300(16):1897-1903.
ABSTRACT FULL TEXT PDF

Standards for Statistical Models Used for Public Reporting of Health Outcomes

An American Heart Association Scientific Statement From the Quality of Care and Outcomes Research Interdisciplinary Writing Group
Cosponsored by the Council on Epidemiology and Prevention and the Stroke Council Endorsed by the American College of Cardiology Foundation Harlan M. Krumholz, Ralph G. Brindis, John E. Brush, David J. Cohen, Andrew J. Epstein, Karen Furie, George Howard, Eric D. Peterson, Saif S. Rathore, Sidney C. Smith, Jr, John A. Spertus, Yun Wang, and Sharon-Lise T. Normand
Circulation. 2006;113:456-462;
Abstract Full Text PDF

Achieving Large System Change in Health Care

John Oldham
JAMA. 2009;301(9):965-966.
EXTRACT FULL TEXT PDF

Patient-Physician Connectedness and Quality of Primary Care

Steven J. Atlas, Richard W. Grant, Timothy G. Ferris, Yuchiao Chang, andMichael J. Barry
Ann Intern Med 2009;150 325-335
Abstract Full Text PDF

Editorial

Is There a Personal Doctor in the House?
Andrew B. Bindman
Ann Intern Med 2009;150 351-352
Full Text PDF

NQF - Safe Practices for Better Healthcare—2009 Update

www.qualityforum.org/safe_practices/

This report from the National Quality Forum (NQF) presents 34 practices that have been demonstrated to be effective in reducing the occurrence of adverse healthcare events.

Diagnostic Errors—The Next Frontier for Patient Safety

David E. Newman-Toker; Peter J. Pronovost
JAMA. 2009;301(10):1060-1062.
EXTRACT FULL TEXT PDF

NPSA - Five actions to improve patient safety reporting

www.npsa.nhs.uk/nrls/reporting/five-actions-to-improve-reporting/
Act on reporting: NHS Confederation - NPSA briefing

Will doctor rating sites improve standards of care? Yes

Neil Bacon
BMJ 2009 338: b1030.
[Extract] [Full Text]

Will doctor rating sites improve the quality of care? No

Margaret McCartney
BMJ 2009 338: b1033.
[Extract] [Full Text]

Pay for Performance: An Overview of the Literature

Stuart E. Greene and David B. Nash
American Journal of Medical Quality 2009 24: 140-163.
[PDF]

CMS's Hospital-Acquired Condition Lists Link Hospital Payment, Patient Safety

Carolyn M. Clancy
American Journal of Medical Quality 2009 24: 166-168.
[PDF]

Relationship of Safety Climate and Safety Performance in Hospitals

Sara Singer, Shoutzu Lin, Alyson Falwell, David Gaba, Laurence Baker
Health Services Research Volume 44 Issue 2p1, Pages 399 - 421
Abstract References HTML, PDF Supporting information

Patient Safety: Contributions by the Agency for Healthcare Research and Quality

www3.interscience.wiley.com/journal/122260191/issue
Health Services Research Volume 44 Issue 2p2

Setting the Stage for the Second Decade of the Era of Patient Safety: Contributions by the Agency for Healthcare Research and Quality and Grantees (p 623-627)
Lee H.
Abstract Full Text: HTML, PDF

Evaluation of the AHRQ Patient Safety Initiative: Framework and Approach (p 628-645)
Donna O. Farley, James B. Battles
Abstract References Full Text: HTML, PDF Supporting information

Assessment of Contributions to Patient Safety Knowledge by the Agency for Healthcare Research and Quality-Funded Patient Safety Projects (p 646-664)
Melony E.S. Sorbero, Karen A. Ricci, Susan Lovejoy, Amelia M. Haviland, Linda Smith, Lily A. Bradley, Liisa Hiatt, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

Experiences of Agency for Healthcare Research and Quality-Funded Projects That Implemented Practices for Safer Patient Care (p 665-683)
Stephanie L. Taylor, M. Susan Ridgely, Michael D. Greenberg, Melony E. S. Sorbero, Stephanie S. Teleki, Cheryl L. Damberg, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

Adopting Information Technology to Drive Improvements in Patient Safety: Lessons from the Agency for Healthcare Research and Quality Health Information Technology Grantees (p 684-700)
Cheryl L. Damberg, M. Susan Ridgely, Rebecca Shaw, Robin C. Meili, Melony E.S. Sorbero, Lily A. Bradley, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

Training a Patient Safety Work Force: The Patient Safety Improvement Corps (p 701-716)
Stephanie S. Teleki, Cheryl L. Damberg, Melony E. S. Sorbero, Rebecca N. Shaw, Lily A. Bradley, Denise D. Quigley, Allen M. Fremont, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

The Growth of Partnerships to Support Patient Safety Practice Adoption (p 717-738)
Peter Mendel, Cheryl L. Damberg, Melony E.S. Sorbero, Danielle M. Varda, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

Safety Outcomes in the United States: Trends and Challenges in Measurement (p 739-755)
Michael D. Greenberg, Amelia M. Haviland, Hao Yu, Donna O. Farley
Abstract References Full Text: HTML, PDF Supporting information

Evaluation of the AHRQ Patient Safety Initiative: Synthesis of Findings (p 756-776) Donna O. Farley, Cheryl L. Damberg
Abstract References Full Text: HTML, PDF Supporting information