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Approach to Improving Safety
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NEWSPAPER/MAGAZINE ARTICLE
Don't underestimate the impact of change on risk potential.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
STUDY
Assessing system failures in operating rooms and intensive care units.
van Beuzekom M, Akerboom SP, Boer F. Qual Saf Health Care. 2007;16:45-50.
COMMENTARY
Improving heparin safety: a multidisciplinary invited conference.
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
COMMENTARY
Random safety auditing, root cause analysis, failure mode and effects analysis.
Ursprung R, Gray J. Clin Perinatol. 2010;37:141-165.
STUDY
Utilising improvement science methods to optimise medication reconciliation.
White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.
STUDY
Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.
Dean J, Hutchinson A, Hamilton Escoto K, Lawson R. BMC Health Serv Res. 2007;7:89.
COMMENTARY
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Lindenauer P. AHRQ WebM&M [serial online]. November 2006.
COMMENTARY
Drill down with root cause analysis.
McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.
COMMENTARY
Case study: identifying potential problems at the human/technical interface in complex clinical systems.
Caudill-Slosberg M, Weeks WB. Am J Med Qual. 2005;20:353-357.
COMMENTARY
Safety strategies in an academic radiation oncology department and recommendations for action.
Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.
SPECIAL OR THEME ISSUE
Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability.
Health Serv Res. 2006;41:1535-1720.
STUDY
Improving communication in the emergency department.
Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-661.
COMMENTARY
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Rich V. AHRQ WebM&M [serial online]. August 2009.
REVIEW
Failure mode and effects analysis application to critical care medicine.
Duwe B, Fuchs BD, Hansen-Flaschen J. Crit Care Clin. 2005;21:21-30, vii.
NEWSPAPER/MAGAZINE ARTICLE
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. 
STUDY
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Varricchio F, Reed J, and the VAERS Working Group. South Med J. 2006;99:486-489.
BOOK/REPORT
2009 Utah Sentinel Events Data Report.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
NEWSPAPER/MAGAZINE ARTICLE
Anticoagulant safety takes center stage in 2007.
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2007;12:1-3.
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