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What's New for 7/22/2009
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 Book/Report

Book/Report
Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report.
The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.

 Journal Article

Commentary
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Delbanco T. JAMA. 2009 July 7; [Epub ahead of print].

Patient Safety Organizations: a new paradigm in quality management and communication systems in healthcare.
Dotan DB. J Clin Eng. 2009;34:142-146.

Review
The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review.
Niazkhani Z, Pirnejad H, Berg M, Aarts J. J Am Med Inform Assoc. 2009;16:539-549.

Study
Cardiovascular medication errors in children.
Alexander DC, Bundy DG, Shore AD, Morlock L, Hicks RW, Miller MR. Pediatrics. 2009;124:324-332.

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency.
Field TS, Rochon P, Lee M, Gavendo L, Baril JL, Gurwitz JH. J Am Med Inform Assoc. 2009;16:480-485.

Disclosing medical errors to patients: it's not what you say, it's what they hear.
Wu AW, Huang IC, Stokes S, Pronovost PJ. J Gen Intern Med. 2009 July 4; [Epub ahead of print].

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.
Gordon JRS, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Ann Intern Med. 2009;151:21-27.

Medical malpractice as reflected by the forensic evaluation of 4450 autopsies.
Madea B, Preuß J. Forensic Sci Int. 2009 June 11; [Epub ahead of print].

Medical negligence in drug associated deaths.
Madea B, Musshoff F, Preuss J. Forensic Sci Int. 2009 June 25; [Epub ahead of print].

Medication error reporting and the work environment in a military setting.
Patrician PA, Brosch LR. J Nurs Care Qual. 2009 July 3; [Epub ahead of print].

Tenfold therapeutic dosing errors in young children reported to US poison control centers.
Crouch BI, Caravati EM, Moltz E. Am J Health Syst Pharm. 2009;66:1292-1296.

Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean.
Schoville RR. J Nurs Care Qual. 2009 July 1; [Epub ahead of print].

Working conditions in primary care: physician reactions and care quality.
Linzer M, Manwell LB, Williams ES, et al for the MEMO (Minimizing Error, Maximizing Outcome) Investigators. Ann Intern Med. 2009;151:28-36.

 Legislation/Regulation

Organizational Policy/Guidelines
Council recommendation on patient safety, including the prevention and control of healthcare associated infections.
Council of the European Union (2009).

 Meeting/Conference

Massachusetts Meeting/Conference
Patient Safety Officer Executive Development Program.
Institute for Healthcare Improvement. September 10-16, 2009; The Charles Hotel, Cambridge, MA.

 Newspaper/Magazine Article

Newspaper/Magazine Article
Medication errors harm millions of Americans each year.
Bavley A. Kansas City Star. July 11, 2009.

When doctors make mistakes.
Chen PW. New York Times. July 9, 2009.

 Special or Theme Issue

Special or Theme Issue
Healthcare-Associated Infections.
Healthc Pap. 2009;9(3):1-62.

 Tools/Toolkit

Toolkit
Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient.
Chicago, IL: Consumers Advancing Patient Safety; 2009.

Implementing the National Patient Safety Goals.
The Joint Commission. August 6-7, 2009, Marriott San Antonio Northwest; San Antonio, TX. 

The Eighth National Quality Colloquium.
Harvard University. August 17-20, 2009; Annenberg Hall, Cambridge, MA.

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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