Hot Topics: References

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Wrong-Site Surgery

Clarke, John R., Janet Johnston, Mary Blanco, and Denise P. Martindell. “Wrong-Site Surgery: Can We Prevent It?” Advances in Surgery [Adv Surg], ISSN: 0065-3411, 42 (2008): 13-31. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/18953807

Gallagher, T. H. “A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery: Review of Medical Error.” JAMA: The Journal of the American Medical Association 302.6 (2009): 669-77. PDF available at: http://jama.ama-assn.org/content/302/6/669.full.pdf.

Stahel P et al. Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-Reported Occurrences. Arch Surg. 2010;145(10):978-984. doi:10.1001/archsurg.2010.185. Available at: http://archsurg.ama-assn.org/cgi/content/full/145/10/978. Accessed 19 Oct. 2011.

Hospital-Acquired Infections

Amanullah S. Ventilator-Associated Pneumonia. Ed. Zab Mosenifar, MD. 31 May 2011. Medscape.com. Available at: http://emedicine.medscape.com/article/304836-overview. Accessed: 26 July 2011.

CDC–Surgical Site Infection (SSI). Centers for Disease Control and Prevention. 12 July 2011. CDC. Available at: http://www.cdc.gov/HAI/ssi/ssi.html. Accessed 27 July 2011.

CDC-FAQs about SSI’s. Centers for Disease Control and Prevention. 24 Nov. 2010. CDC, NCEZID, DHQP. http://www.cdc.gov/HAI/ssi/faq_ssi.html. Accessed 27 July 2011.

FAQs About Surgical Site Infections. SHEA (Society of Healthcare Epidemiology of America). SHEA, IDSA, AHA, APIC, CDC, The Joint Commission. Available at: http://www.sheaonline.org/Assets/files/patient%20guides/NNL_SSI.pdf. Accessed 26 July 2011.

Nash D. High rate of surgical site infections (SSIs) in our nation’s hospitals. http://www.kevinmd.com/blog/2011/03/high-rate-surgical-site-infections-ssis-nations-hospitals.html. Accessed 27 July 2011.

Perl TM and Cosgrove S. Catheter Associated BSI. Johns Hopkins Medicine. Baltimore, Maryland. Centers for Disease Control and Prevention. Available at: http://www.hopkinsmedicine.org/heic/research/catheter.html. Accessed 26 July 2011 .

Vorvick LJ and Hadjiliadis D. Hospital-acquired pneumonia: Medline Plus Medical Encyclopedia. National Library of Medicine – National Institutes of Health. 19 Feb. 2011. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000146.htm. Accessed 27 July 2011.

Wenzel RP and Edmond MB. The impact of hospital-acquired bloodstream infections. Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2631709/. Accessed 26 July 2011 .

Woolcott JC, et al. Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med. 2009;169(21):1952-1960. Available at: http://archinte.ama-assn.org/cgi/content/full/169/21/1952. Accessed Oct. 17, 2011.

Falls

Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic Science 1996;41(5):733–46.

Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.

Hendrich, A., Nyhuuis, A., Kippenbrock, T., & Soga, M.E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8, 129-139.

Lane AJ. Evaluation of the fall prevention program in an acute care setting. Orthopaedic Nursing, (1999) 18, 37-43.

Monane M, Avorn J. Medications and falls. Causation, correlation, and prevention. Clin Geriatr Med. 1996 Nov;12(4):847-58.

Rizzo JA, Friedkin R, Williams CS, Nabors J, Acampora D, Tinetti ME. Health care utilization and costs in a Medicare population by fall status. Medical Care 1998;36(8): 1174–88.

Rubinstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing (September 2006) 35(suppl 2): ii37-ii41 doi:10.1093/ageing/afl084.

Hospital Readmissions

Agency for Healthcare Research and Quality, “Educating Patients Before They Leave the Hospital Reduces Readmissions, Emergency Department Visits and Saves Money,” Feb. 2, 2009, http://www.ahrq.gov/news/press/pr2009/redpr.htm

Clancy CM. Reengineering Hospital Discharge: A Protocol to Improve Patient Safety, Reduce Costs, and Boost Patient Satisfaction. American Journal of Medical Quality. June 2009. Extract available at: http://ajm.sagepub.com/content/early/2009/06/05/1062860609338131.extract Accessed 27 July 2011.

Jencks SF, Williams MV, & Coleman EA. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med. 360:1418-1428. April 2, 2009. Full artcile available at http://www.nejm.org/doi/full/10.1056/NEJMsa0803563. Accessed 27 July 2011.

Reducing Hospital Readmissions With Enhanced Patient Education. Fierce Healthcare — Healthcare News, Hospital News, Healthcare Companies. Fierce Healthcare Custom Publishing and Krames Patient Education. Accessible from: http://www.fiercehealthcare.com/whitepapers/reducing-hospital-readmissions-enhanced-patient-education. Or download PDF here.

Diagnostic Errors

AHRQ Patient Safety Network – Diagnostic Errors. AHRQ Patient Safety Network. Web. Accessed 27 July 2011. Available at: http://psnet.ahrq.gov/primer.aspx?primerID=12.

Diagnostic Error. International Medical Litigation Consultants (Medlit). Electronic Handbook of Legal Medicine. Web. Accessed 27 July 2011. Available at: http://www.medlit.net/member/medical_error_news/menv12i3/diag_error.htm.

Groopman, Jerome. ‘How Doctors Think’ : NPR. 14 Mar. 2007. NPR : National Public Radio. Houghton Miflin Company. Web. 27 July 2011. Available at: http://www.npr.org/templates/story/story.php?storyId=8892053 [Audio and book excerpt].

McNutt, Robert, Richard Abrams, and Scott Hasler. Diagnosing Diagnostic Mistakes. AHRQ WebM&M: Morbidity & Mortality Rounds on the Web. Agency for Healthcare Research and Quality, May 2005. Available at: http://webmm.ahrq.gov/case.aspx?caseID=95.

Newman-Toker DE and Pronovost PJ. Diagnostic Errors–The Next Frontier for Patient Safety. JAMA. 2009;301(10):1060-1062. doi: 10.1001/jama.2009.249. Abstract available at: http://jama.ama-assn.org/content/301/10/1060. Accessed 27 July 2011.

Trowbridge, Robert, and Doug Salvador. Addressing Diagnostic Errors: An Institutional Approach. Focus on Patient Safety – A Newsletter from the National Patient Safety Foundation Volume 13, Issue 3 (2010).

Medication Errors

Facts About Medication Errors: The Case for Improved IV Medication Safety. B | Braun USA. Web. Accessed 27 July 2011. Available at: http://www.bbraunusa.com/index-A3866CA8D0B759A1E395A615A2C006AD.html.

Mansur JM. Enhanced Medication Safety. The Joint Commission International: Medication Safety Articles. Available at: http://www.jointcommissioninternational.org/Medication-Safety-Articles/. Accessed 19 Oct. 2011.

“Medication Errors Symptoms, Diagnosis, Treatments and Causes.” Right Diagnosis.com. Web. 3 Oct. 2011. Available at: http://www.rightdiagnosis.com/m/medication_errors/

Preventing Medical Errors: Report Brief. Institute of Medicine of the National Academies, July 2006. Web. 4 Aug. 2011. PDF available at: http://iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.ashx.

Reducing Medical Errors: Issue Modules, Background Brief. KaiserEDU.org, Health Policy Education from the Henry J. Kaiser Family Foundation. May 2008. Accessed 3 Oct. 2011. Available at: www.kaiseredu.org/Issue-Modules/Reducing-Medical-Errors/Background-Brief.aspx.

What You Can Do To Avoid Medication Errors. Institute of Medicine of the National Academies. Committee on Identifying and Preventing Medication Errors, Institute of Medicine, July 2006. PDF available at: http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsfactsheet.pdf.