September (1) 2012 | Volume 16, Issue 9:1

Table of Contents

1. Bringing Diagnosis into the Quality and Safety Equations
2. Deaths Reported from the Accidental Intrathecal Administration of Bortezomib
3. Deconstructing Intraoperative Communication Failures
4. Events Associated with the Prescribing, Dispensing, and Administering of Medication Loading Doses
5. A Framework for Engaging Physicians in Quality and Safety
6. How Can Health Care Organizations Become More Health Literate?: Workshop Summary
7. Implementing a Surgical Checklist: More Than Checking a Box
8. Improving Team Performance during the Preprocedure Time-Out in Pediatric Interventional Radiology
9. Intraocular Lens Confusions: A Preventable “Never Event”—The Royal Victorian Eye and Ear Hospital Protocol
10. Leadership Best Practices to Prevent Hospital-Associated Infections
11. Making It Easier to Do the Right Thing: A Modern Communication QI Agenda
12. The Patient Safety Curriculum for Undergraduate Medical Students as a First Step toward Improving Patient Safety
13. Patients’ Experiences of Surgical Site Infection
14. Preventable Deaths Due to Problems in Care in English Acute Hospitals: A Retrospective Case Record Review Study
15. Preventable Errors in Organ Transplantation: An Emerging Patient Safety Issue?
16. The Quality Review of the Adverse Incident Reporting System and the Root Cause Analysis of Serious Adverse Surgical Incidents in a Teaching Hospital of Scotland
17. A Resident-Led Institutional Patient Safety and Quality Improvement Process
18. A Safety Culture Transformation: Its Effects at a Children’s Hospital
19. Stem Cells, Dot-Com
20. Study of Nurse Workarounds in a Hospital Using Bar Code Medication Administration System

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