Table of Contents

1. Colorectal Surgery Surgical Site Infection Reduction Program: A National Surgical Quality Improvement–Driven Multidisciplinary Single-Institution Experience
2. Computer Screen Saver Hand Hygiene Information Curbs a Negative Trend in Hand Hygiene Behavior
3. Context, Culture and (Non-Verbal) Communication Affect Handover Quality
4. Effect of an Office-Based Surgical Safety System on Patient Outcomes
5. Global Patient Safety and Antiretroviral Drug–Drug Interactions in the Resource-Limited Setting
6. Improving Patient Safety in the Operating Theatre and Perioperative Care: Obstacles, Interventions, and Priorities for Accelerating Progress
7. “It’s Like Two Worlds Apart”: An Analysis of Vulnerable Patient Handover Practices at Discharge from Hospital
8. The KIDS SAFE Checklist for Pediatric Intensive Care Units
9. Managing the After Effects of Serious Patient Safety Incidents in the NHS: An Online Survey Study
10. Measure, Promote, and Reward Mobility to Prevent Falls in Older Patients
11. A Mixed-Methods Analysis of Patient Reviews of Hospital Care in England: Implications for Public Reporting of Health Care Quality Data in the United States
12. Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes
13. Patient Safety in Midwifery-Led Care in the Netherlands
14. Post-Hospital Syndrome—An Acquired, Transient Condition of Generalized Risk
15. Pressures to “Measure Up” in Surgery: Managing Your Image and Managing Your Patient
16. Preventable Hospital Mortality: Learning from Retrospective Case Record Review
17. Promoting Appropriate Use of Physicians’ Non-English Language Skills in Clinical Care: Recommendations for Policymakers, Organizations and Clinicians
18. Quality in Practice: Implementation of Hospital Guidelines for Patient Identification in Malawi
19. Standardized Patient Identification and Specimen Labeling: A Retrospective Analysis on Improving Patient Safety
20. Successful Implementation of Policies Addressing Lateral Violence

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Table of Contents

1. Anesthesiology Leadership Rounding: Identifying Opportunities for Improvement
2. Changes to Medication-Use Processes after Overdose of U-500 Regular Insulin
3. Disclosure-and-Resolution Programs That Include Generous Compensation Offers May Prompt a Complex Patient Response
4. Errors of Medical Interpretation and Their Potential Clinical Consequences: A Comparison of Professional versus Ad Hoc versus No Interpreters
5. Healing Environment: A Review of the Impact of Physical Environmental Factors on Users
6. Integrating Human Factors Research and Surgery: A Review
7. Learning from Business: Incorporating the Toyota Production System into Nursing Curricula
8. Learning from Taiwan Patient-Safety Reporting System
9. Mapping Out the Emergency Department Disposition Decision for High-Acuity Patients
10. A Multicenter, Phased, Cluster-Randomized Controlled Trial to Reduce Central Line-Associated Bloodstream Infections in Intensive Care Units
11. Patient Involvement in Patient Safety: The Health-Care Professional’s Perspective
12. Poor Communication on Patients’ Medication across Health Care Levels Leads to Potentially Harmful Medication Errors
13. Professionalism in the Era of Duty Hours: Time for a Shift Change?
14. Reasons for Not Reporting Patient Safety Incidents in General Practice: A Qualitative Study
15. Residents’ Duty Hours—Toward an Empirical Narrative
16. Results of an Effort to Integrate Quality and Safety into Medical and Nursing School Curricula and Foster Joint Learning
17. Seven Years of Zero Central-Line-Associated Bloodstream Infections
18. Technology-Related Medication Errors in a Tertiary Hospital: A 5-Year Analysis of Reported Medication Incidents
19. Use of FMEA Analysis to Reduce Risk of Errors in Prescribing and Administering Drugs in Paediatric Wards: A Quality Improvement Report
20. Waking Up the Next Morning: Surgeons’ Emotional Reactions to Adverse Events

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Table of Contents

1. Ambulatory Prescribing Errors among Community-Based Providers in Two States
2. Anatomy of an Incident Disclosure: The Importance of Dialogue
3. Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
4. Defining Patient Safety in Hospice: Principles to Guide Measurement and Public Reporting
5. Emergency Bedside Cesarean Delivery: Lessons Learned in Teamwork and Patient Safety
6. Facilitating Safer Surgery and Anesthesia in a Disaster Zone
7. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review
8. A Framework for Making Patient-Centered Care Front and Center
9. Identifying and Categorising Patient Safety Hazards in Cardiovascular Operating Rooms Using an Interdisciplinary Approach: A Multisite Study
10. Improving Healthcare Quality through Organisational Peer-to-Peer Assessment: Lessons from the Nuclear Power Industry
11. Improving Patient Safety Systems for Patients with Limited English Proficiency: A Guide for Hospitals
12. Inviting Patients to Read Their Doctors’ Notes: A Quasi-Experimental Study and a Look Ahead
13. Medical Errors in US Pediatric Inpatients with Chronic Conditions
14. Nurse Staffing Is an Important Strategy to Prevent Medication Errors in Community Hospitals
15. Order from Chaos: Accelerating Care Integration
16. Predictive Combinations of Monitor Alarms Preceding In-Hospital Code Blue Events
17. Quantification of Anesthesia Providers’ Hand Hygiene in a Busy Metropolitan Operating Room: What Would Semmelweis Think?
18. Recommendations for Safer Radiotherapy: What’s the Message?
19. Simulation Shows Hospitals That Cooperate on Infection Control Obtain Better Results Than Hospitals Acting Alone
20. Supporting a Psychiatric Hospital Culture of Safety

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Table of Contents

1. Case 4—2012: Intrathoracic Fire during Coronary Artery Bypass Graft Surgery
2. The Circulating Nurse’s Role in Error Recovery in the Cardiovascular OR
3. Cognitive Interventions to Reduce Diagnostic Error: A Narrative Review
4. Direct-to-Consumer Disease Screening with Finger-Stick Testing: Online Patient Safety Risks
5. Effect of a Pharmacist Intervention on Clinically Important Medication Errors after Hospital Discharge: A Randomized Trial
6. Hand Hygiene: Necessary but Not Sufficient
7. The Henry Ford Health System No Harm Campaign: A Comprehensive Model to Reduce Harm and Save Lives
8. Hospital-Based Medication Reconciliation Practices: A Systematic Review
9. Impact of Vendor Computerized Physician Order Entry in Community Hospitals
10. Improving Awareness of Best Practices to Reduce Surgical Site Infection: A Multistakeholder Approach
11. Improving Implementation of Infection Control Guidelines to Reduce Nosocomial Infection Rates: Pioneering the Report Card
12. Incidence and Impact of Physician and Nurse Disruptive Behaviors in the Emergency Department
13. Influences Observed on Incidence and Reporting of Medication Errors in Anesthesia
14. The Ins and Outs of Change of Shift Handoffs between Nurses: A Communication Challenge
15. Patient Safety in the Operating Room: An Intervention Study on Latent Risk Factors
16. Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009
17. Review of Patient Safety Incidents Reported from Critical Care Units in North-West England in 2009 and 2010
18. The Role of Nursing Surveillance in Keeping Patients Safe
19. Safety Skills Training for Surgeons: A Half-Day Intervention Improves Knowledge, Attitudes and Awareness of Patient Safety
20. Surgical Safety Checklists: Do They Improve Outcomes?

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Table of Contents

1. Antiretroviral Therapy Prescribing in Hospitalized HIV Clinic Patients
2. The Case for Simulation as Part of a Comprehensive Patient Safety Program
3. Diversion of Drugs within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention
4. Effectiveness and Feasibility of Pharmacist-Led Admission Medication Reconciliation for Geriatric Patients
5. Effectiveness of Implementation of a New Drug Storage Label and Error-Reducing Process on the Accuracy of Drug Dispensing
6. Harm to Healing – Partnering with Patients Who Have Been Harmed
7. Improving Quality through Clinical Risk Management: A Triage Sentinel Event Analysis
8. Improving the Working Relationship between Doctors and Pharmacists: Is Inter-Professional Education the Answer?
9. Medication Reconciliation in the Hospital: What, Why, Where, When, Who and How?
10. Nature and Timing of Incidents Intercepted by the SURPASS Checklist in Surgical Patients
11. Non-Luer Connectors: Are We Nearly There Yet?
12. Patients’ Willingness and Ability to Participate Actively in the Reduction of Clinical Errors: A Systematic Literature Review
13. Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
14. Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect
15. Risks of Online Direct-to-Consumer Tumor Markers for Cancer Screening
16. Surgical Videos for Accident Analysis, Performance Improvement, and Complication Prevention: Time for a Surgical Black Box?
17. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors
18. Using a Risk Assessment Approach to Determine Which Factors Influence Whether Partially Bilingual Physicians Rely on Their Non-English Language Skills or Call an Interpreter
19. Using Root Cause Analysis to Reduce Falls with Injury in the Psychiatric Unit
20. What Near Misses Tell Us about Risk and Safety in Mental Health Care

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• ASPPS Members in the News
• Patient Safety in the News
  • NPSF Welcomes New Board Members
  • Get the Final Check
  • NQF Endorses Complications-Related Patient Safety Measures
  • Improving Patient Safety in Inpatient Units – A Canadian Context

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“Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians”

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012(Jul); 87(7):845–852.

The authors examine the phenomenon of disrespectful behavior by physicians in academic medical settings, arguing that disrespect extends beyond overtly disruptive actions to encompass myriad other forms of incivility and aggression toward nurses, medical trainees, and patients. In this first of a 2-part series, the authors describe ways in which disrespectful behavior is manifested, discuss factors that give rise to and perpetuate a “culture of disrespect,” and examine the destructive and sometimes insidious effects of such behavior on workplace morale, quality of care, and patient safety.

“Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect”

Leape LL, Shore MF, Dienstag JL, et al. Acad Med. 2012(Jul); 87(7):853–858.

In this second of two articles, the authors argue that establishing a workplace culture characterized by mutual respect is a prerequisite for achieving high reliability and safety in the delivery of health care. Noting that health care organizational leaders hold the primary responsibility for effecting this change, the authors outline steps that CEOs must take to promote the development of such a culture and to address disrespectful behavior effectively when it occurs.

Table of Contents

1. Applying HFMEA to Prevent Chemotherapy Errors
2. Development and Evaluation of a 3-Day Patient Safety Curriculum to Advance Knowledge, Self-Efficacy and System Thinking among Medical Students
3. Development of an Evidence-Based Framework of Factors Contributing to Patient Safety Incidents in Hospital Settings: A Systematic Review
4. “Explicitly Implicit”: Examining the Importance of Physician Nonverbal Involvement during Error Disclosures
5. Exploration of Clinically Significant Adverse Events in Adult Non-Traumatic Emergency Department Discharged Patients through the Basic Management Process Analysis – A Five-Year Experience
6. Implementing SBAR across a Large Multihospital Health System
7. Incident Reporting at a Tertiary Care Hospital in Saudi Arabia
8. Is Aviation a Good Model to Study Human Errors in Health Care?
9. Long-Term Reduction in Adverse Drug Events: An Evidence-Based Improvement Model
10. Medication Prescribing Errors in the Prehospital Setting and in the ED
11. Must We Get It Wrong Again? A Simple Intervention to Reduce Medical Error
12. Patient Engagement—What Works?
13. Patients Taking Their Own Medications While in the Hospital
14. Personal Accountability in Healthcare: Searching for the Right Balance
15. A Potentially Hazardous Complication during Central Venous Catheterization: Lost Guidewire Retained in the Patient
16. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, a Global Perspective
17. Prevention of Wrong Site Surgery during Upper Tract Endoscopy
18. The Role of the Patient in Clinical Safety
19. Using Computer-Based Monitoring and Intervention to Prevent Harmful Combinations of Antiretroviral Drugs in the New York State AIDS Drug Assistance Program
20. Wrong Site Surgery—Where Are We and What Is the Next Step?

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Webcast held April 25, 2012, 2-3 pm

Faculty

Rollin J. (Terry) Fairbanks, MD, MS, FACEP
Attending Emergency Physician, MedStar Washington Hospital Center Associate Professor of Emergency Medicine, Georgetown University
Director, National Center for Human Factors Engineering in Healthcare MedStar Institute for Innovation

Please note: Continuing education credits are not available for archived events.

Learning Objectives

Attendees of this webcast will be able to:

• Describe the systems approach to safety engineering
• Describe how human factors engineering can impact safety
• Describe implications of system design, medical device design, and health IT design in this context
• Describe approaches to serious safety event reviews that will produce sustainable results
• Describe how a just culture approach is important to the integration of a system safety engineering approach

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Table of Contents

1. Adverse Event Rates as Measures of Hospital Performance
2. The Canadian Interprofessional Patient Safety Competencies: Their Role in Health-Care Professionals’ Education
3. A Case Study on the Safety Impact of Implementing Smart Patient-Controlled Analgesic Pumps at a Tertiary Care Academic Medical Center
4. Developing and Validating a Scientific Model for Exploring Safe Work Practices in Interdisciplinary Teams
5. The Disclosure of Unanticipated Outcomes of Care and Medical Errors: What Does This Mean for Anesthesiologists?
6. Error-Provoking Conditions in the Medication Use Process: The Case of a Government Hospital in Ghana
7. Handover Patterns: An Observational Study of Critical Care Physician
8. How Hospital Leaders Implemented a Safe Surgery Protocol in Australian Hospitals
9. Improving Accuracy of Medication Identification in an Older Population Using a Medication Bottle Color Symbol Label System
10. Nurses’ Perceptions of Error Reporting and Disclosure in Nursing Homes
11. Online Availability and Safety of Drugs in Shortage: A Descriptive Study of Internet Vendor Characteristics
12. Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs
13. Protocols in the Management of Critical Illness
14. Relating Faults in Diagnostic Reasoning with Diagnostic Errors and Patient Harm
15. Reviewing Methodologically Disparate Data: A Practical Guide for the Patient Safety Research Field
16. Safety Subcultures in Health-Care Organizations and Managing Medical Error
17. Shared Decision Making—The Pinnacle of Patient-Centered Care
18. Strategies to Reduce Medication Errors in Pediatric Ambulatory Settings
19. Violence Prevention Training for Emergency Department Staff
20. Workarounds in the Use of IS in Healthcare: A Case Study of an Electronic Medication Administration System

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