General Articles

Disclosing Medical Errors:  Best Practices from the “Leading Edge” By Eve Shapiro

IOM Report (2000).  To err is human:  Building a safer health system. Available at:
http://books.nap.edu/books/0309068371/html/index.html  

The Patient Safety and Quality Improvement Act of 2005:  Provisions and Potential Opportunities. Liang  BA, Riley W, Rutherford W, Hamman W.  American Journal of Medical Quality, Vol. 22, No.1, Jan/Feb 2007.  http://ajm.sagepub.com

Burstin H, Wakefield M. The Importance of Safety and Quality in Rural America. Journal of Rural Health. (Fall 2004). 20:301-303. Leape LL, Brennan TA, Laird NM, et al.

The nature of adverse events in hospitalized patients.  Results of the Harvard Medical Practice Study II. New England Journal of Medicine. 1991;324(6):377-384.Rudman,W.J., Bailey, J.H., Garrett, P.K., Peden, A., Thomas, E.J., Brown, C.A., (2006). 

Teamwork and safety culture in small rural hospitals in Mississippi.  Patient Safety & Quality Healthcare. Nov/Dec 2006, 46-49.

Managing your organization by the evidence.
Leslie K, Loch M A, Schaninger W. Managing your organization by the evidence. 
The McKinsey Quarterly. June 30, 2006.

CDC Infection Tracking System Now Available to All U.S. Hospitals
A secure, Web-based reporting network that lets facilities track infections associated with health care is now available to all health care facilities in the United States, the Centers for Disease Control and Prevention (CDC) announced today. Read more...

Statistical Brief Details ADEs in Hospitals
AHRQ recently released a statistical brief from the Healthcare Cost and Utilization
Project titled, “Adverse Drug Events in U.S. Hospitals, 2004.” Highlights from the report
include:
• Adverse Drug Events (ADEs) occur in about 3.1 percent of all hospital stays.
• Most ADEs (90.3 percent) were adverse effects of drugs properly administered.
• About 8.6 percent of ADEs were due to drug poisoning: accidental overdose, wrong drugs given or taken, or drugs taken inadvertently.
• Older patients were more likely to experience adverse effects; younger patients were more likely to have poisoning.
• Drugs most commonly associated with ADEs were: corticosteroids, anticoagulants,
anti-cancer and immunosuppressant agents, opiates, and analgesics and fever reducers.
Read the full report at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb29.js

Hospitals redesign to improve patient safety, satisfaction Hospitals are remodeling to better suit patients and families by allowing patients to control room lighting, sound and temperature, and by providing private rooms and spaces for families to spend the night. Some facilities also are incorporating more built-in flexibility as well as information technology, such as EMR systems and computers in every patient room. STLtoday.com/St. Louis Post-Dispatch (9/26)

Cardinal Health Grant Winners for the IHI project.

Rapid Response Teams Can Save Hospitalized Kids
Coordinated care boosts survival of very sick children, study finds