2008 Annual National Patient Safety Foundation Congress: conference proceedings.

Larry Stepnick; Susan Edgman-Levitan; Doug Bonacum; Diane C Pinakiewicz

Meeting/Conference Proceedings

2008 Annual National Patient Safety Foundation Congress: conference proceedings.

September 24, 2008

Stepnick L, Edgman-Levitan S, Bonacum D, et al. J Patient Saf. 2008;4(3).

View more articles from the same authors.

This article summarizes the three plenary sessions of the 2008 National Patient Safety Foundation Congress in Nashville.

Available at

Related Resources From the Same Author(s)

"To Err Is Human" Report Retrospective and the Decade Ahead.

October 21, 2009

2010 Annual National Patient Safety Foundation Congress: conference proceedings.

September 8, 2010

No excuses: the reality that demands action.

September 1, 2005

Strengthening the core. Middle managers play a vital role in improving safety.

January 6, 2010

Transforming concepts in patient safety: a progress report.

August 1, 2018

Healthcare in a land called PeoplePower: nothing about me without me.

March 6, 2005

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.

September 24, 2014

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

June 6, 2012

Surgical team behaviors and patient outcomes.

October 1, 2008

Reducing specimen identification errors.

April 11, 2012

How will state medical boards handle cases involving disclosure and apology for medical errors?

April 27, 2022

Patient safety and diagnostic error: tips for your next shift.

February 3, 2010

Getting to havarti: moving toward patient safety in obstetrics.

November 21, 2007

Where should patient safety be installed?

November 29, 2017

The Sorry Works! Coalition: making the case for full disclosure.

June 7, 2006

Improving patient safety by repeating (read-back) telephone reports of critical information.

March 6, 2005

The impact of electronic health records on diagnosis.

October 4, 2017

Exploration of a rapid response team model of care: a descriptive dual methods study.

September 21, 2022

Integrating human factors research and surgery: a review.

January 16, 2013

Improving care teams' functioning: recommendations from team science.

June 14, 2017

Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.

October 17, 2007

Electronic health record–related events in medical malpractice claims.

January 6, 2016

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

Prejudice in perceptions of physicians?: The influence of race and gender on evaluations of medical errors.

August 8, 2018

Bedside shift reports: what does the evidence say?

September 24, 2014

Autopsy as a quality control measure for radiology, and vice versa.

November 7, 2012

A leadership challenge: staff nurse perceptions after an organizational TeamSTEPPS initiative.

October 17, 2012

Fatigue and safety in paramedicine.

December 18, 2019

Electronic health record challenges, workarounds, and solutions observed in practices integrating behavioral health and primary care.

October 21, 2015

Failure events in transition of care for surgical patients.

March 5, 2014

Teaching nurses to make clinical judgments that ensure patient safety.

August 14, 2019

Using information technology to improve the quality and safety of emergency care.

July 6, 2011

Prescription for error: process defects in a community retail pharmacy.

December 19, 2007

Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 Institute of Medicine resident duty hours recommendations.

August 11, 2010

Lessons learned from implementing a principled approach to resolution following patient harm.

January 9, 2019

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

September 1, 2021

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Patient safety: break the silence.

May 9, 2012

A clinical nurse specialist intervention to facilitate safe transfer from ICU.

November 30, 2011

Leading your organization to high reliability.

April 22, 2009

Different roles, same goal: risk and quality management partnering for patient safety. By the ASHRM Monographs Task Force.

October 24, 2007

Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002.

July 6, 2005

The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience.

June 13, 2007

Impact of high-reliability education on adverse event reporting by registered nurses.

October 10, 2018

Pediatric quality and safety: a nursing perspective.

May 11, 2016

Work-arounds observed by fourth-year nursing students.

November 19, 2014

The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.

April 1, 2015

Medical line entanglement: the unspoken patient safety hazard of medical devices.

May 3, 2023

Standardizing hospital discharge planning at the Mayo Clinic.

January 12, 2011

Nurses improve medication safety with medication allergy and adverse drug reports.

October 3, 2007

Medication errors related to product names.

November 9, 2005

Medication errors involving wrong administration technique.

September 14, 2005

The girl who cried pain: a bias against women in the treatment of pain.

January 2, 2001

Development and evaluation of a required patient safety course.

September 3, 2008

Communication in critical care environments: mobile telephones improve patient care.

February 8, 2006

Creating a stronger culture of safety within US community pharmacies.

April 12, 2023

Painting a picture of nurse presenteeism: a multi-country integrative review.

July 22, 2020

The Safe Tables Collaborative: a statewide experience.

May 4, 2011

Transforming healthcare: a safety imperative.

December 9, 2009

Patient safety in genomic medicine: an exploratory study.

April 13, 2016

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

February 8, 2023

Prescribing patterns of heart failure-exacerbating medications following a heart failure hospitalization.

February 12, 2020

Triggers, bundles, protocols, and checklists—what every maternal care provider needs to know.

April 13, 2016

Nurse health, work environment, presenteeism and patient safety.

July 8, 2020

A work systems analysis approach to understanding fatigue in hospital nurses.

April 5, 2017

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

June 13, 2012

Harmful medication errors in children: a 5-year analysis of data from the USP's MEDMARX(R) program.

August 2, 2006

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

When bad things happen: training medical students to anticipate the aftermath of medical errors.

September 2, 2020

An innovative approach to the surgical time out: a patient-focused model.

June 29, 2016

Understanding the heterogeneity of labor and delivery units: using design thinking methodology to assess environmental factors that contribute to safety in childbirth.

May 8, 2019

Missed and delayed diagnoses of non-COVID conditions--collateral harm from a pandemic.

August 5, 2020

A serious threat to patient safety: the unintended misuse of FentaNYL patches.

May 1, 2013

Sounding the alarm. Nurses, organizations work to address alarm fatigue.

November 20, 2013

The role of nursing surveillance in keeping patients safe.

August 15, 2012

Accelerating the adoption of a safety culture.

April 1, 2015

What's in your kit? A safety checkup may be in order.

November 25, 2015

Do not put medication safety "on hold" with boarded patients.

July 28, 2010

Social risk, health inequity, and patient safety.

October 5, 2022

High-alert medications: shared accountability for risk identification and error prevention.

September 29, 2010

Identified safety risks with splitting and crushing oral medications.

April 7, 2010

Weighing in on medication safety.

December 2, 2009

Choosing the right strategy for medication error reduction—part I and part II.

July 2, 2008

Failure mode and effects analysis: a useful tool for risk identification and injury prevention.

August 8, 2007

Standardizing safety.

August 9, 2006

Is patient safety synonymous with quality nursing care? Should it be? A brief discourse.

November 2, 2005

An elusive balance — residents' work hours and the continuity of care.

July 4, 2007

A safe haven for nurses to report medication errors? Clarian and Spectrum Health Systems prove it is possible!

September 14, 2005

Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system.

January 22, 2020

February 25, 2015

What is known about adverse events in older medical hospital inpatients? A systematic review of the literature.

September 4, 2013

Identification of serious and reportable events in home care: a Delphi survey to develop consensus.

March 5, 2014

Perceptions of nurses who are second victims in a hospital setting.

December 22, 2021

Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.

November 4, 2015

Support for healthcare workers and patients after medical error through mutual healing: another step towards patient safety.

January 18, 2023

The impact of a pharmacist's participation on hospitalists' rounds.

March 10, 2010

Medication errors involving patient-controlled analgesia.

March 5, 2008

Leadership behaviors, attitudes and characteristics to support a culture of safety.

September 28, 2022

Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures.

May 25, 2011

Related Resources

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

October 5, 2022

Addressing the Loss of Trust in Safety Culture.

September 7, 2022

Improving diagnosis: adding context to cognition.

September 7, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

An evolving hospital quality star rating system from CMS: aligning the stars.

May 26, 2021

Risky Business: Navigating a Shifting Health Care Landscape.

April 15, 2021 - April 15, 2021

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

July 29, 2020

An integrative total worker health framework for keeping workers safe and healthy during the COVID-19 pandemic.

July 1, 2020

Diagnostic Strategy for the COVID-19 Pandemic – Bench to Bedside to Blueprint for Policymakers.

April 22, 2020

The harms of promoting 'Zero Harm'.

February 19, 2020

Measuring safety of healthcare: an exercise in futility?

January 15, 2020

Blind spots in the science of safety.

May 8, 2019

Reducing avoidable medication-related harm: what will it take?

May 8, 2019

Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation.

June 28, 2017

Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review.

June 14, 2017

AHRQ Research Summit on Improving Diagnosis in Health Care.

August 17, 2016

Human factors in healthcare: welcome progress, but still scratching the surface.

June 29, 2016

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

May 25, 2016

Medical error—the third leading cause of death in the US.

May 11, 2016

A collaborative learning network approach to improvement: the CUSP learning network.

April 8, 2015

Peer review of medical practices: missed opportunities to learn.

January 28, 2015

Public reporting of patient safety metrics: ready or not?

December 17, 2014

Aviation tools to improve patient safety.

December 17, 2014

'Connecting the dots': leveraging visual analytics to make sense of patient safety event reports.

December 3, 2014

Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.

November 5, 2014

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Safety Scientists

2008 Annual National Patient Safety Foundation Congress: conference proceedings.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

2008 Annual National Patient Safety Foundation Congress: conference proceedings.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site