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.