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. Application of an Aviation Model of Incident Reporting and Investigation to the Neurosurgical Scenario: Method and Preliminary Data
2. As She Lay Dying: How I Fought to Stop Medical Errors from Killing My Mom
3. Counting Matters: Lessons from the Root Cause Analysis of a Retained Surgical Item
4. Duplication of Surgical Site Marking
5. Effects of Nursing Unit Spatial Layout on Nursing Team Communication Patterns, Quality of Care, and Patient Safety
6. A Framework for Encouraging Patient Engagement in Medical Decision Making
7. The Heart of Health Care: Parents’ Perspectives on Patient Safety
8. How-To Guide: Prevent Obstetrical Adverse Events
9. Impact of a Hospital-Wide Hand Hygiene Initiative on Healthcare-Associated Infections: Results of an Interrupted Time Series
10. The Impact of Medication Reconciliation Program at Admission in an Internal Medicine Department
11. Improving Patient Safety through the Systematic Evaluation of Patient Outcomes
12. Online, Direct-to-Consumer Access to Insulin: Patient Safety Considerations and Reform
13. Pediatric Medical Line Safety: The Prevalence and Severity of Medical Line Entanglements
14. Pharmacy Dispensing of Electronically Discontinued Medications
15. The Role of the Electronic Health Record in Patient Safety Events
16. A Study of the Prevalence of Adverse Events in Primary Healthcare in Spain
17. Surgical Fires: Trends Associated with Prevention Efforts
18. A Systematic Approach to the Identification and Classification of Near-Miss Events on Labor and Delivery in a Large, National Health Care System
19. “Team Time-Out” and Surgical Safety—Experiences in 12,390 Neurosurgical Patients
20. Thirty-Day Outcomes Support Implementation of a Surgical Safety Checklist

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• Members in the News
  • ASPPS member Tim Morgenthaler, MD, publishes on Zolpidem as a fall risk for inpatients, in the Journal of Hospital Medicine
• NPSF News
  • The National Patient Safety Foundation’s interim president, Patricia McGaffigan, recently participated in a Congressional briefing on the issue of patient safety and cancer care
• Patient Safety in the News
  • The Joint Commission issues Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
  • Nurse Burnout and Long Shifts
  • A recent article in the New England Journal of Medicine proposes EHR-specific safety goals
• Save the date for the 15th annual NPSF Patient Safety Congress, May 8-10, 2013, in New Orleans. Keynote Speaker: Suzanne Gordon

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Table of Contents

1. Cognitive Errors and Logistical Breakdowns Contributing to Missed and Delayed Diagnoses of Breast and Colorectal Cancers: A Process Analysis of Closed Malpractice Claims
2. A Collaborative, Systems-Level Approach to Eliminating Healthcare-Associated MRSA, Central-Line–Associated Bloodstream Infections, Ventilator-Associated Pneumonia, and Respiratory Virus Infections
3. Diagnostic Errors and Flaws in Clinical Reasoning: Mechanisms and Prevention in Practice
4. Error Reporting in Transfusion Medicine at a Tertiary Care Centre: A Patient Safety Initiative
5. Errors and Near Misses in Digestive Endoscopy Units
6. The Feedback Intervention Trial (FIT)—Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial
7. Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial
8. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation
9. Interruption Handling Strategies during Paediatric Medication Administration
10. Intravascular Retained Surgical Items: A Multicenter Study of Risk Factors
11. Medication Problems Are Frequent and Often Serious in a Danish Emergency Department and May Be Discovered by Clinical Pharmacists
12. Non-Technical Skills Training to Enhance Patient Safety: A Systematic Review
13. Partnering with Family Members to Improve the Intensive Care Unit Experience
14. Patterns in Neurosurgical Adverse Events and Proposed Strategies for Reduction
15. Preventing Wrong-Site Surgery in Minnesota: A 5-Year Journey
16. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes
17. Safety Climate and Medical Errors in 62 US Emergency Departments
18. Sharing Lessons Learned to Prevent Incorrect Surgery
19. Surgical Debriefing: A Reliable Roadmap to Completing the Patient Safety Cycle
20. Ultrasound to Reduce Cognitive Errors in the ED

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Table of Contents

1. Adjusting Team Involvement: A Grounded Theory Study of Challenges in Utilizing a Surgical Safety Checklist as Experienced by Nurses in the Operating Room
2. Adverse Drug Events Caused by Serious Medication Errors
3. Certain Uncertainties: Modes of Patient Safety in Healthcare
4. Designing for Distractions: A Human Factors Approach to Decreasing Interruptions at a Centralised Medication Station
5. Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process
6. The Effect of the WHO Surgical Safety Checklist on Complication Rate and Communication
7. Electronic Health Records and National Patient-Safety Goals
8. More Quality Measures versus Measuring What Matters: A Call for Balance and Parsimony
9. Multiple Patient Safety Events within a Single Hospitalization: A National Profile in US Hospitals
10. A Nurse Learns Firsthand That You May Fend for Yourself after a Hospital Stay
11. Patient Safety Culture in Home Care: Experiences of Home-Care Nurses
12. Procedural Safety in Emergency Care: A Conceptual Model and Recommendations
13. Reduced Mortality with Hospital Pay for Performance in England
14. Rethinking Opioid Prescribing to Protect Patient Safety and Public Health
15. Serious Safety Events: Getting to Zero™
16. A Systematic Review of Hand Hygiene Improvement Strategies: A Behavioural Approach
17. TeamSTEPPS®: The Patient Safety Tool That Needs to Be Implemented
18. Top 10 Health Technology Hazards for 2013
19. Utah Tenth Anniversary (2001-2011) Patient Safety Report: Identifying Opportunities for Improvement
20. What Keeps Facilities from Implementing Best Practices to Prevent Wrong-Site Surgery? Barriers and Strategies for Overcoming Them

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Table of Contents

1.  Characteristics and Costs of Surgical Scheduling Errors
2. Developing a Culture of Safety in the Epilepsy Monitoring Unit: A Retrospective Study of Safety Outcomes
3. The Economic Burden of Patient Safety Targets in Acute Care: A Systematic Review
4. The Economics of Health Care Quality and Medical Errors
5. Effectiveness of a Radiofrequency Detection System as an Adjunct to Manual Counting Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients
6. Effect of Nonpayment for Preventable Infections in U.S. Hospitals
7. Effects of an Online Personal Health Record on Medication Accuracy and Safety: A Cluster-Randomized Trial
8. Evaluating the Evidence: Direct-to-Consumer Screening Tests Advertised Online
9. Impact of Complexity and Computer Control on Errors in Radiation Therapy
10. Improving Medication Safety with Accurate Preadmission Medication Lists and Postdischarge Education
11. Medication Errors in Pediatric Emergencies: A Systematic Analysis
12. Medication Errors, Routines, and Differences between Perioperative and Non-perioperative Nurses
13. Minnesota Hospital Association Statewide Project: SAFE from FALLS
14. The Problem with Peripherally Inserted Central Catheters
15. A Review of Medication Incidents Reported to the National Reporting and Learning System in England and Wales over 6 Years (2005–2010)
16. Risk Factors Associated with Incorrect Surgical Counts
17. Risks Related to Patient Bed Safety
18. Safety Threats and Opportunities to Improve Interfacility Care Transitions: Insights from Patients and Family Members
19. Seen through Their Eyes: Residents’ Reflections on the Cognitive and Contextual Components of Diagnostic Errors in Medicine
20. Types and Patterns of Safety Concerns in Home Care: Staff Perspectives

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• ASPPS News
  • Leadership Transition: A Special Note to Members from Diane Pinakiewicz as she steps down from her positions as president of ASPPS and NPSF
• NPSF News
  • Lucian Leape Institute Report on Care Integration — Order from Chaos: Accelerating Care Integration
  • Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems
• Patient Safety in the News
  • Patient Safety Starts with Nurse Managers
  • Bridging the Health Literacy Gap
  • Caring for Patients with Limited English Proficiency
  • Medication Reconciliation Toolkit
• Upcoming Professional Learning Series Webcasts

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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. Adverse Events among Children in Canadian Hospitals: The Canadian Paediatric Adverse Events Study
2. Disorganized Care: The Findings of an Iterative, In-Depth Analysis of Surgical Morbidity and Mortality
3. An Exploration of Safety Climate in Nursing Homes
4. Exploring Relationships between Patient Safety Culture and Patients’ Assessments of Hospital Care
5. Falls Risk Assessment: A Foundational Element of Falls Prevention Programs
6. Frequency of and Harm Associated with Primary Care Safety Incidents
7. Identifying Early Warning Signs for Diagnostic Errors in Primary Care: A Qualitative Study
8. Implementing a Nurse-Shadowing Program for First-Year Medical Students to Improve Interprofessional Collaborations on Health Care Teams
9. Improved Climate, Culture, and Communication through Multidisciplinary Training and Instruction
10. Improving Patient Handovers from Hospital to Primary Care: A Systematic Review
11. Is It Possible to Identify Risks for Injurious Falls in Hospitalized Patients?
12. Medication Communication between Nurses and Patients during Nursing Handovers on Medical Wards: A Critical Ethnographic Study
13. Nurse-to-Physician Communications: Connecting for Safety
14. Participation in Unprofessional Behaviors among Hospitalists: A Multicenter Study
15. Patients’ and Health Care Professionals’ Attitudes towards the PINK Patient Safety Video
16. Putting the ‘Patient’ in Patient Safety: A Qualitative Study of Consumer Experiences
17. The Role of Talking (and Keeping Silent) in Physician Coping with Medical Error: A Qualitative Study
18. ‘Tempos’ Management in Primary Care: A Key Factor for Classifying Adverse Events, and Improving Quality and Safety
19. What Diabetic Patients Do and What Should They Do to Avoid Errors in the Course of Treatment?
20. Why Patients Need Leaders: Introducing a Ward Safety Checklist

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