Study What does it take? A case study of radical change toward patient safety. Citation Text: Vicente KJ. What does it take? A case study of radical change toward patient safety. Jt Comm J Qual Patient Saf. 2003;29(11):598-609. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 6, 2005 Vicente KJ. Jt Comm J Qual Patient Saf. 2003;29(11):598-609. View more articles from the same authors. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Vicente KJ. What does it take? A case study of radical change toward patient safety. Jt Comm J Qual Patient Saf. 2003;29(11):598-609. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Problems with medical devices may be severely under-reported. June 8, 2005 International evaluation of an AI system for breast cancer screening. January 29, 2020 Retained surgical items: a problem yet to be solved. October 31, 2012 Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. September 24, 2014 From patients to politicians: a cognitive engineering view of patient safety. March 27, 2005 Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study. September 13, 2023 Surgery is in itself a risk factor for the patient. June 1, 2022 Validation of a reduced set of high-performance triggers for identifying patient safety incidents with harm in primary care. November 8, 2023 Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable. May 17, 2023 Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities. January 11, 2017 Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study. March 15, 2017 Technology-induced errors associated with computerized provider order entry software for older patients. August 23, 2017 Medication errors involving nursing students: a systematic review. February 7, 2018 Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. September 12, 2012 Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. February 26, 2020 Robotic dispensing improves patient safety, inventory management, and staff satisfaction in an outpatient hospital pharmacy. September 12, 2018 Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit. April 6, 2011 Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. November 23, 2005 Using social and behavioural science to support COVID-19 pandemic response. June 3, 2020 The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018 Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. November 1, 2023 Pictograms, units and dosing tools, and parent medication errors: a randomized study. July 19, 2017 Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. May 31, 2017 Liquid medication errors and dosing tools: a randomized controlled experiment. October 5, 2016 A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014 Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016 Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. April 29, 2015 Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. April 24, 2019 Frequency and outcome of cervical cancer prevention failures in the United States. December 19, 2007 Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic. March 23, 2022 Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure. March 9, 2022 Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. August 10, 2022 Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study. September 13, 2023 The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study. January 26, 2022 The Lancet Commission on lessons for the future from the COVID-19 pandemic. October 12, 2022 Challenges and strategies for patient safety in primary care: a qualitative study. September 28, 2022 Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023 Factors influencing in-hospital prescribing errors: a systematic review. July 19, 2023 Bracing for the storm: one health care system's planning for the COVID-19 surge. November 11, 2020 Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. June 23, 2021 Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis. September 2, 2020 Cognitive error in an academic emergency department. October 10, 2018 A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. July 26, 2017 Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery. August 9, 2017 From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. March 1, 2017 Reducing Avoidable Readmissions Effectively campaign: a statewide collaborative. February 5, 2014 Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. October 10, 2012 Effects of health information technology on patient outcomes: a systematic review. November 16, 2016 Beyond the team: understanding interprofessional work in two North American ICUs. August 19, 2015 Current issues in patient safety in surgery: a review. July 1, 2015 A professional development course improves unprofessional physician behavior. February 12, 2020 Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. June 19, 2019 Structured override reasons for drug–drug interaction alerts in electronic health records. May 15, 2019 The prevalence of wrong level surgery among spine surgeons. January 30, 2008 Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. October 5, 2005 Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. May 10, 2006 The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer. July 19, 2006 Creating a safety culture at the Children's and Women's Health Centre of British Columbia. February 7, 2007 Results of a survey on medical error reporting systems in Korean hospitals. August 31, 2005 Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. December 2, 2009 ReCASTing the RCA: an improved model for performing root cause analyses. May 26, 2010 John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. March 6, 2005 Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study. March 4, 2020 Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. July 8, 2020 Patient safety measurement tools used in nursing homes: a systematic literature review. December 7, 2022 Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. September 29, 2021 National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. July 17, 2013 Missed breast cancers at US-guided core needle biopsy: how to reduce them. March 7, 2007 Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. March 2, 2022 Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022 Stigma and healthcare access among transgender and gender-diverse people: a qualitative meta-synthesis. July 20, 2022 Assessing biases in medical decisions via clinician and AI chatbot responses to patient vignettes. November 1, 2023 Implementing strategies to prevent home medication administration errors in children with medical complexity. October 18, 2023 Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation. September 20, 2023 Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers. August 23, 2023 Status of patient safety culture in community pharmacy settings: a systematic review. August 23, 2023 Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19. November 17, 2021 The exaggerated benefits of failure. June 26, 2024 Prescribing decision making by medical residents on night shifts: a qualitative study. November 9, 2022 Duplicate medication order errors: safety gaps and recommendations for improvement. October 12, 2022 WebM&M Cases Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. March 8, 2023 Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022 Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care. May 11, 2022 Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019. April 27, 2022 Habit and automaticity in medical alert override: cohort study. April 27, 2022 Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists. March 20, 2024 Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. February 7, 2024 Patient safety culture: the impact on workplace violence and health worker burnout. February 8, 2023 How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022 Exploring the intersection of structural racism and ageism in healthcare. December 7, 2022 Patient safety in nursing homes from an ecological perspective: an integrated review. January 17, 2024 Diagnostic accuracy of a large language model in pediatric case studies. January 17, 2024 The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents. November 15, 2023 Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact. April 19, 2023 Overlapping surgery in arthroplasty - a systematic review and meta-analysis. July 5, 2023 Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study. May 5, 2021 A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: a prospective cohort study. February 3, 2021 Interventions to engage patients and families in patient safety: a systematic review. January 20, 2021 Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. January 13, 2021 View More Related Resources Health Services Safety Investigations Body. October 1, 2023 Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023 Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 "Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses. March 22, 2023 Improving clinician well-being and patient safety through human-centered design. March 8, 2023 Cognitive aids in the management of clinical emergencies: a systematic review. January 18, 2023 Perspective Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Interview In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022 Patient Safety Innovations Journal Article Study The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. November 16, 2022 Intravenous smart pumps at the point of care: a descriptive, observational study. October 12, 2022 Development and pilot evaluation of an electronic health record usability and safety self-assessment tool. August 24, 2022 Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. July 27, 2022 Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. July 20, 2022 Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system. March 23, 2022 Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022 Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses. June 9, 2021 Preventing violence in the health care setting. June 9, 2021 Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. April 15, 2021 - April 15, 2021 Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis. March 10, 2021 Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021 From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment. February 10, 2021 Never Events Analysis of HSIB's National Investigations Report. February 3, 2021 Awareness of human factors in the operating theatres during the COVID-19 pandemic. January 13, 2021 Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. November 25, 2020 Interventions and measurements of highly reliable/resilient organization implementations: a literature review. October 28, 2020 High-Performance Work Systems in Health Care Management: Parts 1-5. October 4, 2020 Patient Safety Primers COVID-19: Team and Human Factors to Improve Safety July 30, 2020 Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. September 18, 2019 View More See More About The Topic Quality and Safety Professionals Organizational Behaviorists Human Factors Engineering
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. September 24, 2014
Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study. September 13, 2023
Validation of a reduced set of high-performance triggers for identifying patient safety incidents with harm in primary care. November 8, 2023
Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable. May 17, 2023
Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities. January 11, 2017
Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study. March 15, 2017
Technology-induced errors associated with computerized provider order entry software for older patients. August 23, 2017
Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. September 12, 2012
Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. February 26, 2020
Robotic dispensing improves patient safety, inventory management, and staff satisfaction in an outpatient hospital pharmacy. September 12, 2018
Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit. April 6, 2011
Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. November 23, 2005
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. November 1, 2023
Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency. May 31, 2017
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus. March 26, 2014
Preventability and causes of readmissions in a national cohort of general medicine patients. May 4, 2016
Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. April 29, 2015
Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. April 24, 2019
Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic. March 23, 2022
Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure. March 9, 2022
Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. August 10, 2022
Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study. September 13, 2023
The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study. January 26, 2022
Challenges and strategies for patient safety in primary care: a qualitative study. September 28, 2022
Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023
Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. June 23, 2021
Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis. September 2, 2020
A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients. July 26, 2017
Understanding the multidimensional effects of resident duty hours restrictions: a thematic analysis of published viewpoints in surgery. August 9, 2017
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system. March 1, 2017
Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. October 10, 2012
Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. June 19, 2019
Structured override reasons for drug–drug interaction alerts in electronic health records. May 15, 2019
Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. October 5, 2005
Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. May 10, 2006
The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer. July 19, 2006
Creating a safety culture at the Children's and Women's Health Centre of British Columbia. February 7, 2007
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. December 2, 2009
John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. March 6, 2005
Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study. March 4, 2020
Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. July 8, 2020
Patient safety measurement tools used in nursing homes: a systematic literature review. December 7, 2022
Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. September 29, 2021
National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA. July 17, 2013
Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. March 2, 2022
Stigma and healthcare access among transgender and gender-diverse people: a qualitative meta-synthesis. July 20, 2022
Assessing biases in medical decisions via clinician and AI chatbot responses to patient vignettes. November 1, 2023
Implementing strategies to prevent home medication administration errors in children with medical complexity. October 18, 2023
Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation. September 20, 2023
Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers. August 23, 2023
Status of patient safety culture in community pharmacy settings: a systematic review. August 23, 2023
Prescribing decision making by medical residents on night shifts: a qualitative study. November 9, 2022
The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. March 8, 2023
Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022
Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care. May 11, 2022
Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019. April 27, 2022
Designing human-centered AI to prevent medication dispensing errors: focus group study with pharmacists. March 20, 2024
Society of Critical Care Medicine Guidelines on Recognizing and Responding to Clinical Deterioration Outside the ICU: 2023. February 7, 2024
How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022
Patient safety in nursing homes from an ecological perspective: an integrated review. January 17, 2024
The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents. November 15, 2023
Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact. April 19, 2023
Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study. May 5, 2021
A poison information centre can provide important assessment and guidance regarding medication errors in nursing homes: a prospective cohort study. February 3, 2021
Interventions to engage patients and families in patient safety: a systematic review. January 20, 2021
Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. January 13, 2021
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Interview In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023
Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023
"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses. March 22, 2023
Perspective Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022
Patient Safety Innovations Journal Article Study The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. November 16, 2022
Development and pilot evaluation of an electronic health record usability and safety self-assessment tool. August 24, 2022
Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room. July 27, 2022
Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. July 20, 2022
Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system. March 23, 2022
Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022
Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses. June 9, 2021
Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders. April 15, 2021 - April 15, 2021
Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis. March 10, 2021
Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. February 24, 2021
From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment. February 10, 2021
Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. November 25, 2020
Interventions and measurements of highly reliable/resilient organization implementations: a literature review. October 28, 2020
Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents. September 18, 2019