Advances in Patient Safety: New Directions and Alternative Approaches represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and other topics related to improving patient safety.
The 115 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. The volumes are organized around four broad themes: volume 1, assessment; volume 2, culture and redesign; volume 3, performance and tools; and volume 4, information technology and medication safety. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present tools and products that can be used to improve patient safety. This new publication complements AHRQ's Advances in Patient Safety: From Research to Implementation, published in 2005.
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Contents
Volume 1. Assessment
Volume 2. Culture and Redesign
Volume 3. Performance and Tools
Volume 4. Technology and Medication Safety
Volume 1. Assessment
Title Page and Citation( 
PDF, 18 KB)
Preface. Carolyn Clancy ( PDF, 19 KB)
Acknowledgements ( PDF, 57 KB)
Table of Contents ( PDF, 57 KB)
Prologue to the Volume. Kerm Henriksen ( PDF, 21 KB)
Looking Forward, Benefitting from the Past
Envisioning Patient Safety in 2025: Eight Perspectives ( PDF, 83 KB)
Kerm Henriksen, et al.
What Exactly is Patient Safety? ( PDF, 555 KB)
Linda Emanuel, et al.
Reporting Systems
Improving the Value of Patient Safety Reporting Systems PDF, 81 KB
Peter J. Provonost, et al.
The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data ( PDF, 266 KB)
Katherine J. Jones, et al.
Proactive Post-Marketing Surveillance ( PDF, 69 KB)
Robert R. Campbell, et al.
The Medical Product Safety Network (MedSun) Collaborates with Medical Product Users to Create Specialty Subnetworks within the Larger Framework of MedSun ( PDF, 100 KB)
Donna Engleman, et al.
Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology ( PDF, 109 KB)
Martin November, et al..
26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System ( PDF, 802 KB)
Debora Simmons, et al..
Using An Anonymous Web-based Incident Reporting Tool to Embed the Principles of a High Reliability Organization ( PDF, 118 KB)
Paul Conlon, et al.
Voluntary Adverse Event Reporting in Rural Hospitals ( PDF, 478 KB)
Charles P. Schade, et al.
Improving Error Reporting in Ambulatory Pediatrics with Team Approach ( PDF, 358 KB)
Daniel R. Neuspiel, et al..
Relationship Between Patient Harm and Reported Medical Errors in Primary Care: A Report from the ASIPS Collaborative ( PDF, 91 KB)
David R. West, et al..
Structure and Features of a Care Enhancement Model Implementing the Patient Safety and Quality Improvement Act ( PDF, 211 KB)
William Riley, et al..
Taxonomies and Measurement
Development of a Comprehensive Medical Error Ontology ( PDF, 893 KB)
Pallavi Mokkarala, et al.
Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy ( PDF, 133 KB)
John R. Clarke, et al.
A System to Describe and Reduce Medical Errors in Primary Care ( PDF, 448 KB)
Victoria Kaprielian, et al.
Beyond Nursing Quality Measurement: The Nation's First Regional Nursing Virtual Dashboard ( PDF, 1 MB)
Carolyn E. Aydin, et al.
Using ICD-9-CM Codes in Hospital Claims Data to Detect Adverse Events in Patient Safety Surveillance ( PDF, 227 KB)
Paul Hougland, et al.
Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium ( PDF, 570 KB)
Hude Quan, et al.
Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration ( PDF, 223 KB)
Stephenie L. Shimada, et al.
Challenges and Lessons Learned
Patient Safety Learning Pilot: Narratives from the Frontlines ( PDF, 608 KB)
Shirley E Kellie, et al.
A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care ( PDF, 3 MB)
Ranjit Singh, et al.
Christiana Care Health System: Safety Mentor Program ( PDF, 501 KB)
Michele Campbell, et al.
News Media and Health Care Providers at the Crossroads of Medical Adverse Events ( PDF, 129 KB)
Pamela Whitten, et al.
Risk Assessment
Risk-Based Patient Safety Metrics ( PDF, 614 KB)
Matthew C. Scanlon, et al.
Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning ( PDF, 433 KB)
Donna M. Woods, et al.
A Model of Care Delivery to Reduce Falls in a Major Cancer Center ( PDF, 426 KB)
Nancy E. Kline, et al.
Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care ( PDF, 338 KB)
Mary L. Hook, et al.
Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings ( PDF, 156 KB)
Robyn R.M. Gershon, et al.
Cause Analysis
The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (Advances 2 - Volume 1 - Faltz_56 )
Lawrence L. Faltz, et al.
Department of Veterans Affairs Emergency Airway Management Initiative ( PDF, 104 KB)
Erik J. Stalhandske, et al.
Using Root Cause Analysis to Reduce Falls in Rural Health Care Facilities ( PDF, 338 KB)
Patricia Ruddick, et al.
Common Cause Analysis: Focus on Institutional Change ( PDF, 387 KB)
Anne Marie Browne, et al.
Peer Reviewers
Peer Reviewers—Volume 1 ( PDF, 237 KB)
Volume 2. Culture and Redesign
Title Page and Citation ( PDF, 18 KB)
Preface. Carolyn Clancy ( PDF, 19 KB)
Acknowledgements ( PDF, 17 KB)
Prologue to the Volume. James Battles ( PDF, 20 KB)
Safety Culture and Organizational Issues
The AHRQ Hospital Survey on Patient Safety Culture: A Tool to Plan and Evaluate Patient Safety Programs ( PDF, 750 KB)
Katherine J. Jones
Hospital Administrative Staff vs. Nursing Staff Responses to the AHRQ Hospital Survey on Patient Safety Culture ( PDF, 546 KB)
Karen L. Hannah, et al.
Using the AHRQ Hospital Survey on Patient Safety Culture as an Intervention Tool for Regional Clinical Improvement Collaboratives ( PDF, 133 KB)
Inga Adams-Pizarro, et al.
Measuring Safety Climate in Primary Care Offices ( PDF, 603 KB)
Gurdev Singh, et al.
The PeaceHealth Ambulatory Medication Safety Culture Survey ( PDF, 381 KB)
Ronald Stock, et al.
Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Healthcare System Following the National Standard of Care ( PDF, 301 KB)
Hardeek H. Shah, et al.
Is There an Association between Patient Safety Indicators and Hospital Teaching Status? ( PDF, 327 KB)
Peter E. Rivard, et al.
Organizational Behavior Management in Healthcare: Applications for Large-Scale Improvements in Patient Safety ( PDF, 205 KB)
Thomas R. Cunningham, E. Scott Geller,
Confidential Performance Feedback and Organizational Capacity Building to Improve Hospital Patient Safety: Results of a Randomized Trial ( PDF, 154 KB)
Peter M. Layde, et al.
Clinical Process Improvement
Resident Sign-Out: A Precarious Exchange of Critical Information in a Fast-Paced World ( PDF, 616 KB)
Stephen M. Borowitz, et al.
Documentation of Mandated Discharge Summary Components in Transitions from Acute to Sub-Acute Care ( PDF, 97 KB)
Amy J. H. Kind, Maureen A. Smith
Challenges to Real-Time Decision Support in Healthcare ( PDF, 263 KB)
Mark Fitzgerald, et al.
Risk Reduction and Systematic Error Management: Standardization of the Pediatric Chemotherapy Process ( PDF, 667 KB)
Beverly Ann David, et al.
Analysis of Patient Safety: Converting Complex Pediatric Chemotherapy Ordering Processes From Paper to Electronic Systems ( PDF, 452 KB)
Donald K. Baker, et al.
Promoting Best Practice and Safety through Preprinted Physician Orders ( PDF, 199 KB)
George Ehringer, Barbara Duffy
The Impact of Standardized Order Sets on Quality and Financial Outcomes ( PDF, 586 KB)
David J Ballard, et al.
Clinical Impact of an Anticoagulation Screening Service at a Pediatric Tertiary Care Facility ( PDF, 431 KB)
Kathy M. Harney, et al.
Creating Safety in the Testing Process in Primary Care Offices ( PDF, 414 KB)
Nancy C. Elder, et al.
Role of the External Coach in Advancing Research Translation in Hospital-based Performance Improvement ( PDF, 158 KB)
Nancy Donaldson, et al.
Strategies for Improving Patient Safety in Small Rural Hospitals ( PDF, 134 KB)
Judith Tupper, et al.
Systems Redesign
Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work ( PDF, 91 KB)
Julie K. Johnson, et al.
Designing the Built Environment for the Culture and System of Patient Safety-A Conceptual, New Design Process ( PDF, 490 KB)
Kenneth N. Dickerman, Paul Barach
Implementation of Systems Redesign: Approaches to Spread and Sustain Adoption ( PDF, 598 KB)
Heather Woodward Hagg, et al.
Transforming the Morbidity and Mortality Conference into an Instrument for System-wide Improvement ( PDF, 359 KB)
Jamie N. Deis, et al.
Collaboratives and Patient Involvement
The Patient Safety Education Project: An International Collaboration ( PDF, 485 KB)
Linda Emanuel, et al.
Harnessing the Potential of Healthcare Collaboratives: Lessons from the Keystone ICU Project ( PDF, 117 KB)
Christine Goeschel, et al.
VHA's National Falls Collaborative and Prevention Programs ( PDF, 578 KB)
Erik Stalhandske, et al.
Hospital Language Services: Quality Improvement and Performance Measures ( PDF, 128 KB)
Marsha Regenstein, et al.
Using Patient Complaints to Promote Patient Safety ( PDF, 414 KB)
James W. Pichert, et al.
From Public Testimony to Vehicle for Statewide Action: Experience of the Michigan State Commission on Patient Safety ( PDF, 620 KB)
Diane Valade, et al.
The Rural Physician Peer Review Model: A Virtual Solution ( PDF, 422 KB)
Josie Williams, et al.
Peer Reviewers
Peer Reviewers—Volume 2 ( PDF, 237 KB)
Volume 3. Performance and Tools
Title Page and Citation ( PDF, 18 KB)
Preface. Carolyn Clancy ( PDF, 19 KB)
Acknowledgements ( PDF, 17 KB)
Table of Contents ( PDF, 21 KB)
Prologue to the Volume. Margaret Keyes ( PDF, 21 KB)
Teamwork and Communication
TeamSTEPPS™: Team Strategies and Tools to Enhance Performance and Patient Safety ( PDF, 466 KB)
Heidi B. King, et al.
Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement with Promising Teamwork Tools and Strategies ( PDF, 455 KB)
John S. Webster, et al.
Building Self-Empowered Teams for Improving Safety in Post-operative Pain ( PDF, 1 MB)
Ranjit Singh, et al.
Beyond Rapid Response Teams: Instituting a "Rover Team" Improves the Management of At Risk Patients, Facilitates Proactive Interventions and Improves Outcomes ( PDF, 598 KB)
Remi M. Hueckel, et al.
Improving Referral Communication Using a Referral Tool Within an Electronic Record ( PDF, 156 KB)
Tejal K. Gandhi, et al.
Improving Patient Safety through Provider Communication Strategy Enhancements ( PDF, 599 KB)
Catherine Dingley, et al.
Improving Clinical Communication and Patient Safety: Clinician Recommended Solutions ( PDF, 150 KB)
Donna M. Woods, et al.
Simulation
In Situ Simulation: Challenges and Results ( PDF, 144 KB)
Mary D. Patterson, et al.
The Nature, Characteristics and Patterns of Perinatal Critical Events Teams ( PDF, 355 KB)
William Riley, et al.
Failure Mode and Effects Analysis Based on In-Situ Simulations: A Methodology to Improve Understanding of Risks and Failures ( PDF, 135 KB)
Stanley Davis, et al.
The Mobile Mock Operating Room: Bringing Team Training to the Point of Care ( PDF, 1.5 MB)
John T. Paige, et al.
Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training ( PDF, 1 MB)
Ramnarayan Paragi Gururaja, et al.
Effect of Recent Refresher Training on In Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance ( PDF, 648 KB)
Akira Nishisaki, et al.
Simulation-Based Education Improves Patient Safety in Ambulatory Care ( PDF, 581 KB)
Beth A. LaVelle, et al.
Human Factors
Pillars of a Smart, Safe Operating Room ( PDF, 109 KB)
F. Jacob Seagull, et al.
High Hanging Fruit: Improving Transitions in Healthcare ( PDF, 100 KB)
Shawna J. Perry, et al.
Minding the Gaps: Creating Resilience in Healthcare ( PDF, 550 KB)
Christopher Nemeth, et al.
Error Producing Conditions in the Intensive Care Unit ( PDF, 475 KB)
Frank A. Drews, et al.
Patient Monitors in Critical Care: Lessons for Improvement ( PDF, 122 KB)
Frank A. Drews
Tools and Practices
Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The Re-Engineered Discharge (RED) Program ( PDF, 151 KB)
Brian Jack, et al.
Creating an Accurate Medication List in the Outpatiet Setting Through a Patient-Centered Approach ( PDF, 143 KB)
Kathryn Kraft Leonhardt, et al.
The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems ( PDF, 502 KB)
Gregg S. Meyer, et al.
Using Data Mining to Predict Errors in Chronic Disease Care ( PDF, 660 KB)
Ryan M. McCabe, et al.
Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety ( PDF, 134 KB)
Brenda K. Zierler, et al.
Using Process Measures to Improve Patient Safety Practices to Prevent Pulmonary Embolism ( PDF, 438 KB)
Ellen Flink, et al.
A Tool to Assess Compliance in Anticoagulation Management ( PDF, 585 KB)
Carla S. Huber, et al.
Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories within a Community ( PDF, 438 KB)
Brion Hurley, et al.
Using Six Sigma® Methodology to Improve Handoff Communication in High Risk Patients ( PDF, 585 KB)
Kshitij P. Mistry, et al.
10 Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma, and Team Training All Thrive in a Single Hospital? ( PDF, 510 KB)
Jon N. Meliones, et al.
Impact of Staff-Led Safety Walk Rounds ( PDF, 379 KB)
Vicki L. Montgomery, et al.
Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet) ( PDF, 676 KB)
Niraj L. Sehgal, et al.
Peer Reviewers
Peer Reviewers—Volume 3 ( PDF, 237 KB)
Volume 4. Technology and Medication Safety
Title Page and Citation ( PDF, 18 KB)
Preface. Carolyn Clancy ( PDF, 19 KB)
Acknowledgements ( PDF, 17 KB)
Table of Contents ( PDF, 91 KB)
Prologue to the Volume. Mary Grady ( PDF, 21 KB)
Health Information Technology
"Safeware": Safety-critical Computing and Healthcare Information Technology ( PDF, 109 KB
Robert L. Wears, et al.
Improving Perioperative Patient Safety ( PDF, 97 KB)
Paul St. Jacques, and Michael Minear
The Impact of Health Information Technology on Work Process and Patient Care on Labor and Delivery ( PDF, 606 KB)
Emily M. Campbell, et al.
Consolidated Imaging: Implementing a Regional Health Information Exchange System for Radiology in Southern Maine ( PDF, 455 KB)
Stephenie Loux, et al.
Personal Health Records to Improve Health Information Exchange and Patient Safety ( PDF, 803 KB)
James R. Fricton, Diane Davie
Improving Patient Safety Using ATHENA-Decision Support System Technology: The Opiod Therapy for Chronic Pain Experience ( PDF, 536 KB)
Martha Michel, et al.
Implementing an Ambulatory e-Prescribing System: Strategies Employed and Lessons Learned to Minimize Unintended Consequences ( PDF, 121 KB)
Emily B. Devine, et al.
Measuring IT Sophistication in Nursing Homes ( PDF, 216 KB)
Gregory L. Alexander, et al.
The Potential of Hand-held Assistive Technology to Improve Safety for Elder Adults Aging in Place ( PDF, 728 KB)
Shirley Ann Becker, Frank M. Webbe.
Efficiency Gains with Computerized Provider Order Entry ( PDF, 76 KB)
Andrew M. Steele, et al.
Medication Safety
Clinical Pharmacists in Emergency Medicine ( PDF, 116 KB)
Rollin J. Fairbanks, et al.
Intravenous Infusion Safety Initiative: Collaboration, Evidence-based Best Practices and "Smart" Technology Help Avert High-risk Adverse Drug Events and Improve Patient Outcomes ( PDF, 486 KB)
Ray Maddox, et al.
Continuous Respiratory Monitoring and "Smart" Infusion System Improve Safety of Patient-Controlled Anesthesia in the Postoperative Period ( PDF, 724 KB)
Ray R. Maddox, et al.
Evaluation of a Medication Therapy Management Program in Medicare Beneficiaries at High Risk of Adverse Drug Events: Study Methods ( PDF, 646 KB)
Andrew L. Masica, et al.
Medication Management Transactions and Errors in Family Medicine Offices: A Pilot Study ( PDF, 116 KB)
John Lynch, et al.
Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes ( PDF, 75 KB)
Karla Miller, et al.
Imbedding Research in Practice to Improve Medication Safety ( PDF, 182 KB)
Marsha A. Raebel, et al.
Risk of Concurrent Use of Prescription Drugs with Herbal and Dietary Supplements in Ambulatory Care ( PDF, 177 KB)
Robert E. Graham, et al.
Using Home Visits to Understand Medication Errors in Children ( PDF, 622 KB)
Kathleen E. Walsh, et al.
Developing a Community-Wide Electronic Shared Medication List ( PDF, 608 KB)
Ron Stock, et al.
