Improving heparin safety: a multidisciplinary invited conference.

Carl Peterson; Charles W Ham; Tim Vanderveen

Meeting/Conference Proceedings

Improving heparin safety: a multidisciplinary invited conference.

July 23, 2008

Peterson C, Ham CW, Vanderveen T.

View more articles from the same authors.

This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.

Available at

Related Resources From the Same Author(s)

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

July 10, 2019

Physician reporting of clinically significant events through a computerized patient sign-out system.

September 14, 2011

Management of the difficult airway: a closed claims analysis.

July 13, 2005

WebM&M Cases

Vial Mistakes Involving Heparin

May 1, 2009

Relationship between physician burnout and the quality and cost of care for Medicare beneficiaries is complex.

April 20, 2022

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

March 8, 2023

Implementing high-reliability organization principles into practice: a rapid evidence review.

November 11, 2020

Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.

October 28, 2020

Outcomes of medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis.

July 21, 2021

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge.

January 8, 2020

Hospital nurse staffing and patient mortality, emotional exhaustion, and job dissatisfaction.

October 26, 2005

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

Understanding principles of high reliability organizations through the eyes of VIONE: a clinical program to improve patient safety by deprescribing potentially inappropriate medications and reducing polypharmacy.

February 5, 2020

Making Healthcare Safe: The Story of the Patient Safety Movement.

June 9, 2021

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

Enteral feeding misconnections: a consortium position statement.

May 7, 2008

Alarm management: first things first: using reliable data to eliminate unnecessary alarms.

December 10, 2014

Smart pumps: advanced capabilities and continuous quality improvement.

February 14, 2007

Medication safety technologies: what is and is not working.

July 29, 2009

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

March 6, 2005

Effects on resident work hours, sleep duration and work experience in a Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS).

June 26, 2019

Mitigating the July effect.

July 7, 2021

Differences in medication errors between central and remote site telepharmacies.

October 17, 2012

Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project.

September 21, 2011

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

January 11, 2006

Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors.

September 5, 2012

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up.

July 18, 2018

Transformational improvement in quality care and health systems: the next decade.

November 25, 2020

“I’m concerned”: a multi-site assessment of emergency medicine resident speaking up behaviors.

December 21, 2022

Using text mining techniques to identify health care providers with patient safety problems: exploratory study.

October 13, 2021

Harnessing the power of medical malpractice data to improve patient care.

January 8, 2020

Measuring hospital-acquired complications associated with low-value care.

March 6, 2019

Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice.

April 11, 2018

Safety analysis over time: seven major changes to adverse event investigation.

January 24, 2018

Learning from failure: the need for independent safety investigation in healthcare.

November 19, 2014

Mortality review as a tool to assess the contribution of healthcare-associated infections to death: results of a multicentre validity and reproducibility study, 11 European Union countries, 2017 to 2018.

August 4, 2021

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

March 17, 2010

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

January 11, 2023

Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation.

October 21, 2020

Association of the Hospital Readmissions Reduction Program implementation with readmission and mortality outcomes in heart failure.

November 22, 2017

Prevalence and nature of adverse medical device events in hospitalized children.

June 26, 2013

Mobile physician reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident on call activities.

December 3, 2014

Guided prescription of psychotropic medications for geriatric inpatients.

May 18, 2005

Adverse drug events in ambulatory care.

March 6, 2005

The incidence and severity of adverse events affecting patients after discharge from the hospital.

March 6, 2005

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

June 21, 2017

Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.

March 23, 2016

Medication reconciliation at hospital discharge: a qualitative exploration of acute care nurses' perceptions of their roles and responsibilities.

March 23, 2022

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department.

July 27, 2022

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation.

December 15, 2021

Naming the "baby" or the "beast"? The importance of concepts and labels in healthcare safety investigation.

April 5, 2023

Investigating hospital supervision: a case study of regulatory inspectors' roles as potential co-creators of resilience.

April 14, 2021

Ensuring primary care diagnostic quality in the era of telemedicine.

October 27, 2021

Accuracy of emergency department clinical findings for diagnosis of coronavirus disease 2019.

July 29, 2020

How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials.

September 7, 2005

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

May 24, 2023

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

February 13, 2008

Creating an integrated patient safety team.

August 10, 2005

Adverse events following an emergency department visit.

February 28, 2007

Findings from the ISMP Medication Safety Self-Assessment for hospitals.

March 6, 2005

Medication errors resulting from computer entry by nonprescribers.

May 6, 2009

The Research on Adverse Drug Events and Reports (RADAR) project.

May 18, 2005

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Effect of reducing interns' work hours on serious medical errors in intensive care units.

March 27, 2005

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

December 1, 2021

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

February 17, 2021

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Misdiagnosis of heart failure: a systematic review of the literature.

July 28, 2021

Serious misdiagnosis-related harms in malpractice claims: the "Big Three": vascular events, infections, and cancers.

July 17, 2019

Patient safety: Part I. Patient safety and the dermatologist.

August 19, 2009

Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting.

March 6, 2005

Polypharmacy and potentially inappropriate medication in people with dementia: a nationwide study.

June 13, 2018

Family involvement in managing medications of older patients across transitions of care: a systematic review.

June 26, 2019

Action on patient safety can reduce health inequalities.

April 13, 2022

Embracing multiple aims in healthcare improvement and innovation.

March 23, 2022

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

January 11, 2023

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Surgical patient safety officers in the United States: negotiating contradictions between compliance and workplace transformation.

February 24, 2021

Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical center.

October 21, 2020

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

A spike in people dying at home suggests coronavirus deaths in Houston may be higher than reported.

July 22, 2020

Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

April 19, 2017

No excuses: the reality that demands action.

September 1, 2005

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

A safe practice standard for barcode technology.

June 3, 2015

Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room.

October 8, 2008

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

January 2, 2008

Recovery from medical errors: the critical care nursing safety net.

January 31, 2006

Attitudinal changes resulting from repetitive training of operating room personnel using high-fidelity simulation at the point of care.

September 16, 2009

High-fidelity, simulation-based, interdisciplinary operating room team training at the point of care.

February 25, 2009

Effect of reducing interns' weekly work hours on sleep and attentional failures.

March 27, 2005

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

September 20, 2023

Diagnostic Errors in the Emergency Department: A Systematic Review.

December 21, 2022

Evidence Brief: Implementation of High Reliability Organization Principles.

July 24, 2019

‘I am not the doctor for you’: physicians’ attitudes about caring for people with disabilities.

October 26, 2022

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Related Resources

Patient Safety Authority Annual Reports.

April 30, 2024

Patient Safety Innovations

Suicide Prevention in an Emergency Department Population: ED-SAFE

April 24, 2024

Annual Perspective

Equity in Patient Safety

March 27, 2024

Annual Perspective

Communication During Transitions of Care

March 27, 2024

Interview

In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0

February 28, 2024

Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement.

February 6, 2024

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

November 15, 2023

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States.

June 21, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

A health system that won't learn from its mistakes.

September 21, 2022

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

October 7, 2021

WebM&M Cases

Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?

April 29, 2020

Stakeholder perceptions of smart infusion pumps and drug library updates: a multisite, interdisciplinary study.

September 25, 2019

Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?

April 24, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

Improving the communication between teams managing boarded patients on a surgical specialty ward.

August 31, 2016

The frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study.

March 16, 2016

Shining a Light: Safer Health Care Through Transparency.

January 28, 2015

Medication event huddles: a tool for reducing adverse drug events.

January 15, 2014

Engaging patients in medication reconciliation via a patient portal following hospital discharge.

October 2, 2013

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

May 22, 2013

Survey results: community liaison programs to decrease hospital readmissions.

March 20, 2013

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

See More About The Topic

Hospitals

Health Care Providers

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Improving heparin safety: a multidisciplinary invited conference.

Suicide Prevention in an Emergency Department Population: ED-SAFE

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving heparin safety: a multidisciplinary invited conference.

Suicide Prevention in an Emergency Department Population: ED-SAFE

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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