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What's New for 8/6/2008
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 Audiovisual

Audiovisual
Hospitals bar code babies to prevent medical mistakes.
Randles T. WSMV.com. July 18, 2008.

Software glitches pose new, potentially dangerous problems for medical devices.
Kennedy D. "iHealthBeat." California Healthcare Foundation. July 25, 2008. 

 Award

Award Recipient
Four hospitals honored for commitment to quality.
Chicago, IL. American Hospital Association; July 24, 2008.

 Journal Article

Commentary
Human factors and systems engineering approach to patient safety for radiotherapy.
Rivera AJ, Karsh B-T. Int J Radiat Oncol Biol Phys. 2008;71:S174-S177.

Managing an acute adverse event in a radiology department.
Kruskal JB, Siewert B, Anderson SW, Eisenberg RL, Sosna J. Radiographics. 2008 Jul 6; [Epub ahead of print].

Review
Life after death: the aftermath of perioperative catastrophes.
Gazoni FM, Durieux ME, Wells L. Anesth Analg. 2008;107:591-600.

Study
A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs.  
Phillips DP, Barker GEC, Eguchi MM. Arch Intern Med. 2008;168:1561-1566.  

Building a simulation-based crisis resource management course for emergency medicine, phase 1: results from an interdisciplinary needs assessment survey.
Hicks CM, Bandiera GW, Denny CJ. Acad Emerg Med. 2008 Jul 14; [Epub ahead of print].

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.
Gandara E, Moniz TT, Ungar J, et al. Jt Comm J Qual Patient Saf. 2008;34:460-463.

Does the Leapfrog program help identify high-quality hospitals?
Jha AK, Orav EJ, Ridgway AB, Zheng J, Epstein AM. Jt Comm J Qual Patient Saf. 2008;34:318-325.

Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review.
Talsma A, Bahl V, Campbell DA. J Nurs Care Qual. 2008;23:202-210.

Impact of miscommunication in medical dispute cases in Japan.
Aoki N, Uda K, Ohta S, Kiuchi T, Fukui T. Int J Qual Health Care. 2008 Jul 17; [Epub ahead of print].

Surgical management and outcomes of 165 colonoscopic perforations from a single institution.
Iqbal CW, Cullinane DC, Schiller HJ, et al. Arch Surg. 2008;143:701-707.

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.
Encinosa WE, Hellinger FJ. Health Serv Res. 2008 Jul 25; [Epub ahead of print].

Use of a computerized forcing function improves performance in ordering restraints.
Griffey RT, Wittels K, Gilboy N, McAfee AT. Ann Emerg Med. 2008 Jul 21; [Epub ahead of print].

 Meeting/Conference

Canada Meeting/Conference
The Canadian Healthcare Safety Symposium 8: Healthcare and the Law.
BUKSA Conference Management and Program Development. October 23-25, 2008; Winnipeg Convention Centre, Winnipeg, Manitoba, Canada.

 Newspaper/Magazine Article

Newspaper/Magazine Article
Heparin errors continue despite prior, high-profile, fatal events.
ISMP Medication Safety Alert! Acute Care Edition. July 17, 2008;13:1-2.

When it's surgery, don't get it wrong.
Grant T. Washington Post. July 22, 2008:HE01

 Special or Theme Issue

Special or Theme Issue
2009 National Patient Safety Goals: the official, approved goals and helpful solutions for meeting them.
Jt Comm Perspect Patient Saf. 2008;8:1-12.

 Tools/Toolkit

Measurement Tool/Indicator
Pediatric Patient Safety in the Emergency Department - Survey Preview Version.
Oakbrook Terrace, IL: Joint Commission Resources; 2008.

AHRQ 2008 Annual Conference.
Agency for Healthcare Research and Quality. September 7-10, 2008; North Bethesda Marriott, Bethesda, MD. 

Safety Across High-Consequence Industries Conference.
Center for Aviation Safety Research, Saint Louis University. September 10-12, 2008; Saint Louis University Campus, St Louis, MO.

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