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What's New for 7/16/2008
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 Book/Report

Book/Report
High Quality Care for All: NHS Next Stage Review Final Report.
Darzi A. National Health Service. London, England: Crown Publishing; June 2008. ISBN: 9780101743228.

Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.
Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058

 Journal Article

Commentary
Twelve tips for teaching avoidance of diagnostic errors.
Trowbridge RL. Med Teach. 2008;30:496-500.

Study
Adverse event protocol for interventional pain medicine: the importance of an organized response.
Sitzman BT. Pain Med. 2008;9:S108-S112.

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.
Sittig DF, Ash JS, Guappone KP, Campbell EM, Dykstra RH. Int J Med Inform. 2008;77:440-447. 

Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States.
Bonis PA, Pickens GT, Rind DM, Foster DA. Int J Med Inform. 2008 Jun 19; [Epub ahead of print].

Emergency medical services provider perceptions of the nature of adverse events and near-misses in out-of-hospital care: an ethnographic view. 
Fairbanks RJ, Crittenden CN, O'Gara KG, et al. Acad Emerg Med. 2008;15:633-640.

Functional health literacy and understanding of medications at discharge.
Maniaci MJ, Heckman MG, Dawson NL. Mayo Clin Proc. 2008;83:554-558. 

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.
Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-87. 

Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency.
Thomas AN, Panchagnula U. Anaesthesia. 2008;63:726-733.

Prevalence of adverse drug combinations in a large post-mortem toxicology database.
Launiainen T, Vuori E, Ojanperä I. Int J Legal Med. 2008 Jun 27; [Epub ahead of print].

Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.

Reliability of a revised NOTECHS scale for use in surgical teams.
Sevdalis N, Davis R, Koutantji M, et al. Am J Surg. 2008 Jun 16; [Epub ahead of print].

 Legislation/Regulation

Organizational Policy/Guidelines
Behaviors that undermine a culture of safety.
Sentinel Event Alert. July 9, 2008.   

 Newspaper/Magazine Article

Newspaper/Magazine Article
Barcode technology flaws put some patients at risk.
U.S. News & World Report. July 3, 2008.

Epidural-IV route mix-ups: reducing the risk of deadly errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.

Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008:Metro section:1A.

Hospitals work to cure errors: concern about Medicare changes prompts review.
Rogers C. Detroit News. June 30, 2008;Business section:1C.

 Press Release/Announcement

Press Release/Announcement
4th International Conference on Patient- and Family-Centered Care: Partnerships for Quality and Safety: Call for Papers.
Bethesda, MD: Institute for Family-Centered Care; July 3, 2008.

The National Patient Safety Foundation Research Program.
North Adams, MA: National Patient Safety Foundation; 2008.

Using Data Effectively to Manage the Risks to Medication Safety.
US Pharmacopeia, Institute for Safe Medication Practices. July 24, 2008; New Jersey Hospital Association Conference Center, Princeton, NJ. 

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