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What's New for 7/1/2009
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 Book/Report

Book/Report
Review of Patient Safety for Children and Young People.
London, UK: National Patient Safety Agency; 2009. ISBN: 978906624071.

 Journal Article

Commentary
Implementing a team-based daily goals sheet in a non-ICU setting.
Holzmueller CG, Timmel J, Kent PS, Schulick RD, Pronovost PJ. Jt Comm J Qual Patient Saf. 2009;35:384-388.

Intentionally harmful violations and patient safety: the example of Harold Shipman.
Baker R, Hurwitz B. J R Soc Med. 2009;102:223-227.

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.
Clancy CM. Am J Med Qual. 2009 Jun 5; [Epub ahead of print].

Refocusing the lens: patient safety in ambulatory chronic disease care.
Sarkar U, Wachter RM, Schroeder SA, Schillinger D. Jt Comm J Qual Patient Saf. 2009;35:377-383.

The role of medical liability reform in federal health care reform.
Mello MM, Brennan TA. N Engl J Med. 2009 June 15; [Epub ahead of print]. 

Study
Between choice and chance: the role of human factors in acute care equipment decisions.
Nemeth C, Nunnally M, Bitan Y, Nunnally S, Cook RI. J Patient Saf. 2009;5:114-121.

Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients.
Rosen AK, Loveland SA, Romano PS, et al. Med Care. 2009;47:723-731.

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.
Calligaris L, Panzera A, Arnoldo L, et al. BMC Clin Pharmacol. 2009;9:9.

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.
Ford EC, Gaudette R, Myers L, et al. Int J Radiat Oncol Biol Phys. 2009;74:852-858.

Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture.
Pringle J, Weber RJ, Rice K, Kirisci L, Sirio C. Am J Med Qual. 2009 June 15; [Epub ahead of print].

Interruptions and geographic challenges to nurses' cognitive workload.
Redding DA, Robinson S. J Nurs Care Qual. 2009;24:194-200.

Parental misinterpretations of over-the-counter pediatric cough and cold medication labels.
Lokker N, Sanders L, Perrin EM, et al. Pediatrics. 2009;123:1464-1471.

Probability error in diagnosis: the conjunction fallacy among beginning medical students.
Rao G. Fam Med. 2009;41:262-265.

Safety and efficiency considerations for the introduction of electronic ordering in a blood bank.
Georgiou A, Greenfield T, Callen J, Westbrook JI. Arch Pathol Lab Med. 2009;133:933-937.

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.
Zsenits B, Polashenski WA, Sterns RH, Brown DR IV, Moheet A. J Hosp Med. 2009;4:308-312.

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.
Zecevic AA, Salmoni AW, Lewko JH, Vandervoort AA, Speechley M. Gerontologist. 2009 June 12; [Epub ahead of print].

 Meeting/Conference

Florida Meeting/Conference
Peer Review: The Fundamental Background of Quality Management. ABQAURP's 32nd Annual Health Care Quality & Patient Safety Conference.
American Board of Quality Assurance and Utilization Review Physicians, Inc. November 7, 2009; Disney's BoardWalk Resort, Lake Buena Vista, FL.

 Newspaper/Magazine Article

Newspaper/Magazine Article
At VA hospital, a rogue cancer unit.
Bogdanich W. New York Times. June 20, 2009;National Desk:1.

 Tools/Toolkit

Measurement Tool/Indicator
Medication Safety Self Assessment for Automated Dispensing Cabinets.
Horsham, PA: Institute for Safe Medication Practices; 2009.  

Patient Safety Grant Program.
Dublin, OH: Cardinal Health, Inc.

The Pediatric National Conference: Safe Care, Quality Care, We Care.
Joint Commission and Joint Commission Resources. July 22-23, 2009; Joint Commission Conference Center, Oakbrook Terrace, IL.

AHRQ's 2009 Annual Conference—Research to Reform: Achieving Health System Change.
Agency for Healthcare Research and Quality. September 13–16, 2009; North Bethesda Marriott, Bethesda, MD.

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