Advances in Patient Safety

From Research to Implementation. Volumes 1-4

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last 5 years. This compendium is sponsored jointly by the ��Ƶ (AHRQ) and the Department of Defense (DoD)-Health Affairs.

The 140 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present useful tools and products that can be used to improve patient safety.

For print versions of articles, download the PDFs.

Acknowledgments
Preface
Volume 1. Research Findings (��ƵPublication No. 05-0021-1)
Volume 2. Concepts and Methodology (��ƵPublication No. 05-0021-2)
Volume 3. Implementation Issues (��ƵPublication No. 05-0021-3)
Volume 4. Programs, Tools, and Products (��ƵPublication No. 05-0021-4)

Volume 1. Research Findings (��ƵPublication No. 05-0021-1)

Prologue: ( PDF, 121 KB)
Brent C. James

The Clinical Environment

( PDF, 155 KB)
Bradley Evanoff, Patricia Potter, Laurie Wolf, Deborah Grayson, Clay Dunagan, Stuart Boxerman
( PDF, 208 KB)
Timothy J. Hoff, Henry Pohl, Joel Bartfield
( PDF, 318 KB)
Patricia Potter, Laurie Wolf, Stuart Boxerman, Deborah Grayson, Jennifer Sledge, Clay Dunagan, Bradley Evanoff
( PDF, 172 KB)
Deborah Grayson, Stuart Boxerman, Patricia Potter, Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff
( PDF, 187 KB)
Mark Linzer, Linda Baier Manwell, Marlon Mundt, Eric Williams, Ann Maguire, Julia McMurray, Mary Beth Plane
( PDF, 230 KB)
Andrea M. Spehar, Robert R. Campbell, Carron Cherrie, Polly Palacios, Donna Scott, Jacquelyn L. Baker, Brad Bjornstad, Jay Wolfson

Medication Safety

( PDF, 376 KB)
Kimberly A. Galt, Ann M. Rule, Bartholomew E. Clark, James D. Bramble, Wendy Taylor, Kevin G. Moores
( PDF, 217 KB)
Elizabeth Duthie, Barbara Favreau, Angelo Ruperto, Janet Mannion, Ellen Flink, Ruth Leslie
( PDF, 287 KB)
Radhika Desikan, Melissa J. Krauss, W. Claiborne Dunagan, Erin Christensen Rachmiel, Thomas Bailey, Victoria J. Fraser
( PDF, 183 KB)
Thomas G. Rundall, John Hsu, Jennifer Elston Lafata, Vicki Fung, Kathryn A. Paez, Jan Simpkins, Steven R. Simon, Scott B. Robinson,
Connie Uratsu, Margaret J. Gunter, Stephen B. Soumerai, Joseph V. Selby
( PDF, 174 KB)
Joseph G. Weaver, Judy Enders McManus, Tammy Leung, Rhonda B. Mangione, Heidi R. Snow, Stacie K. Hackworth
( PDF, 172 KB)
Dustin D. French, Andrea M. Spehar, Robert R. Campbell, Polly Palacios, Roy W. Coakley, Nicholas Coblio, Heidi Means, Dennis C. Werner, David M. Angaran
( PDF, 254 KB)
Dean Schillinger, Eddie Machtinger, Frances Wang, Maytrella Rodriguez, Andrew Bindman
( PDF, 260 KB)
Valerie J. Reige

Surveillance

( PDF, 268 KB)
Carol J. Masheter, Paul Hougland, Wu Xu
( PDF, 185 KB)
Mark Van Tuinen, Susan Elder, Carolyn Link, Susan Li, John H. Song, Tracey Pritchett
( PDF, 194 KB)
Robert R. Campbell, Douglas D. Bradham, Aurora Sanchez-Anguiano, Dennis H. Werner, Andrea M. Spehar, Dustin French, Polly Palacios
( PDF, 185 KB)
Mary Rojas, Alan Silver, Christine Llewellyn, Lenora Rances
( PDF, 476 KB)
Rosa M. Cotayo, Holly A. Grems, Elizabeth Sloan
( PDF, 177 KB)
Donald R. Woolever

Technology

( PDF, 430 KB)
Christopher Nemeth, Mark Nunnally, Michael O'Connor, P. Allan Klock, Richard Cook
( PDF, 232 KB)
Albert S. Chan, Susana B. Martins, Robert W. Coleman, Hayden B. Bosworth, Eugene Z. Oddone, Michael G. Shlipak, Samson W. Tu,
Mark A. Musen, Brian B. Hoffman, Mary K. Goldstein
( PDF, 140 KB)
Todd R. Johnson, Jiajie Zhang, Vimla L. Patel, Alla Keselman, Xiaozhou Tang, Juliana J. Brixey, Danielle Paige, James P. Turley

Ambulatory and Rural

( PDF, 186 KB)
Julie J. Mohr, Carole M. Lannon, Kathleen A. Thoma, Donna Woods, Eric J. Slora, Richard C. Wasserman, Lynne Uhring
( PDF, 204 KB)
Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush
( PDF, 135 KB)
Ann Freeman Cook, Helena Hoas, Katarina Guttmannova
( PDF, 184 KB)
Stephenie L. Loux, Susan M. C. Payne, Astrid Knott

Policy and Medical Expenditures

( PDF, 186 KB)
Joanna Weinberg, Lee H. Hilborne, Quang-Tuyen Nguyen
( PDF, 242 KB)
William E. Encinosa, Fred J. Hellinger
( PDF, 194 KB)
Didem Bernard, William E. Encinosa

Peer Reviewers—Volume 1

Volume 2. Concepts and Methodology (��ƵPublication No. 05-0021-2)

Prologue: ( PDF, 105 KB)
Paul M. Schyve

Measurement and Taxonomies

( PDF, 218 KB)
Peter E. Rivard, A. Rani Elwy, Susan Loveland, Shibei Zhao, Dennis Tsilimingras, Anne Elixhauser, Patrick S. Romano, Amy K. Rosen
( PDF, 186 KB)
Brian Gallagher, Liyi Cen, Edward L. Hannan
( PDF, 197 KB)
Brian Gallagher, Liyi Cen, Edward L. Hannan
( PDF, 174 KB)
Amy R. Wilson, Bryan E. Dowd, John E. Kralewski
( PDF, 186 KB)
Wilson D. Pace, Douglas H. Fernald, Daniel M. Harris, L. Miriam Dickinson, Rodrigo Araya-Guerra, Elizabeth W. Staton, Rebecca VanVorst, Bennett L. Parnes, Deborah S. Main
( PDF, 362 KB)
Bruce Thomadsen, Shi-Woei Lin
( PDF, 277 KB)
Katrin S. Kohl, Jan Bonhoeffer, M. Miles Braun, Robert T. Chen, Philippe Duclos, Harald Heijbel, Ulrich Heininger, Elisabeth Loupi, S. Michael Marcy, the Brighton Collaboration

Surveillance

( PDF, 185 KB)
David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder, Lisa J. Jaser, Nancy Safer, Paul Davern
( PDF, 196 KB)
Peter M. Layde, Linda N. Meurer, Clare Guse, John R. Meurer, Hongyan Yang, Prakash Laud, Evelyn M. Kuhn, Karen J. Brasel, Stephen W. Hargarten
( PDF, 239 KB)
Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Marr, Javán Quintela, Deborah S. Main
( PDF, 187 KB)
Sharon K. Martin, Jason M. Etchegaray, Debora Simmons, W. Thomas Belt, Kelly Clark

Medication Safety

( PDF, 189 KB)
David J. Magid, Paul A. Estabrooks, David W. Brand, Marsha A. Raebel, Ted E. Palen, John F. Steiner, Eli J. Korner, David W. Bates, Richard Platt, Russell E. Glasgow
( PDF, 164 KB)
Andrew C. Seger, Tejal K. Gandhi, Carol Hope, J. Marc Overhage, Michael D. Murray, David Weber, Julie Fiskio, Evgenia Teal, David W. Bates
( PDF version - 187.19 KB )
Emily Beth Devine, Jennifer L. Wilson-Norton, Nathan M. Lawless, Thomas K. Hazlet, Ryan Hansen, Kerry Kelly, Stephanie Te, Carolyn Wong
( PDF, 527 KB)
Dean Schillinger, Edward L. Machtinger, Frances Wang, Lay-Leng Chen, Karen Win, Jorge Palacios, Maytrella Rodriguez, Andrew Bindman
( PDF, 203 KB)
Heather McPhillips, Christopher Stille, David Smith, John Pearson, John Stull, Julia Hecht, Susan Andrade, Marlene Miller, Robert Davis
( PDF, 237 KB)
K. Arnold Chan for the HMO Research Network CERT Patient Safety Investigators

Cognition, Systems, and Risk

( PDF, 226 KB)
Pat Croskerry
( PDF, 247 KB)
Gordon D. Schiff, Seijeoung Kim, Richard Abrams, Karen Cosby, Bruce Lambert, Arthur S. Elstein, Scott Hasler, Nela Krosnjar, Richard Odwazny, Mary F. Wisniewski, Robert A. McNutt
( PDF, 809 KB)
Christopher Nemeth, Michael O'Connor, P. Allan Klock, Richard Cook
( PDF, 333 KB)
Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush, George Biltz
( PDF, 197 KB)
Ravi Behara, Robert L. Wears, Shawna J. Perry, Eric Eisenberg, Lexa Murphy, Mary vanderHoeff, Marc Shapiro, Christopher Beach, Pat Croskerry, Karen Cosby
(PDF, 313 KB)
Jiajie Zhang, Vimla L. Patel, Todd R. Johnson, Philip Chung, James P. Turley
( PDF, 185 KB)
Ben-Tzion Karsh, Samuel J. Alper
( PDF, 250 KB)
Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt, Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks, Tanita L. Robert, Myra Enloe, Rupa Sheth, Sade Sobande
( PDF, 260 KB)
Michelle L. Rogers, Emily Patterson, Roger Chapman, Marta Render
( PDF, 327 KB)
David Anthony, VK Chetty, Anand Kartha, Kathleen McKenna, Maria Rizzo DePaoli, Brian Jack
( PDF, 246 KB)
Sharon Conrow Comden, David Marx, Margaret Murphy-Carley, Misti Hale
( PDF, 180 KB)
Richard S. Marken

Safety Culture and Organizational Issues

( PDF, 2.22 MB)
John G. Reiling
( PDF, 213 KB)
Veronica F. Nieva, Robert Murphy, Nancy Ridley, Nancy Donaldson, John Combes, Pamela Mitchell, Christine Kovner, Elizabeth Hoy, Deborah Carpenter
( PDF, 171 KB)
Rangaraj Ramanujam, Donna J. Keyser, Carl A. Sirio
( PDF, 220 KB)
Patricia W. Stone, Michael I. Harrison, Penny Feldman, Mark Linzer, Timothy Peng, Douglas Roblin, Jill Scott-Cawiezell, Nicholas Warren, Eric S. Williams
( PDF, 200 KB)
Stephanie Fein, Lee Hilborne, Margie Kagawa-Singer, Eugene Spiritus, Craig Keenan, Gregory Seymann, Kaveh Sojania, Neil Wenger

Volume 3. Implementation Issues (��ƵPublication No. 05-0021-3)

( PDF, 85 KB)
Lucian L. Leape

Information Technology

( PDF, 639 KB)
Denise Hartnett Daudelin, Manlik Kwong, Joni R. Beshansky, Harry P. Selker
( PDF, 496 KB)
Marie-Jocelyne Charles, Bart J. Harmon, Pamela S. Jordan
( PDF, 276 KB)
Adrianne C. Feldstein, David H. Smith, Nan R. Robertson, Christine A. Kovach, Stephen B. Soumerai, Steven R. Simon, Dean F. Sittig, Daniel S. Laferriere, Mara Kalter
( PDF, 225 KB)
Gabriel J. Escobar, Bruce F. Folck, Marla N. Gardner, June Ma, Larry I. Palmer, Bryan Liang, Linda K. Nozick
( PDF, 317 KB)
Christie Teigland, Richard Gardiner, Hailing Li, Colene Byrne
( PDF, 224 KB)
K. Bruce Bayley, Lucy A. Savitz, Glenn Rodriguez, William Gillanders, Steve Stoner

Surveillance

( PDF, 246 KB)
David R. West, John M. Westfall, Rodrigo Araya-Guerra, Laura Hansen, Javán Quintela, Rebecca VanVorst, Elizabeth W. Staton, Bethany Matthews, Wilson D. Pace
( PDF, 194 KB)
Robert L. Phillips, Susan M. Dovey, John S. Hickner, Deborah Graham, Michele Johnson
( PDF, 220 KB)
Ellen Flink, C. Lynn Chevalier, Angelo Ruperto, Peg Dameron, Frederick J. Heigel, Ruth Leslie, Janet Mannion, Robert J. Panzer
( PDF, 184 KB)
Carl A. Sirio, Donna J. Keyser, Heidi Norman, Robert J. Weber, Carlene A. Muto
( PDF, 161 KB)
Michelle L. Harper, Robert L. Helmreich
( PDF, 172 KB)
Harvey J. Murff, Daniel W. Byrne, Paul A. Harris, Daniel J. France, Christa Hedstrom, Robert S. Dittus
( PDF, 180 KB)
William J. Rudman, Jessica H. Bailey, Carol Hope, Paula Garrett, C. Andrew Brown
( PDF, 203 KB)
Sharon K. Ulep, Sheryl L. Moran
( PDF, 144 KB)
Marilyn Flack, Terrie Reed, Jay Crowley, Susan Gardner
( PDF, 140 KB)
Mary Ann Davis, Geoffrey W. Rake

Interventions

( PDF, 230 KB)
Kimberly A. Galt, Ann M. Rule, Wendy Taylor, Mark Siracuse, J.D. Bramble, Eugene C. Rich, Wayne Young, Bartholomew Clark, Bruce Houghton
( PDF, 194 KB)
John A. Savino, Jane Smeland, Ellen L. Flink, Angelo Ruperto, Amanda Hines, Thomas Sullivan, Kerri Galvin, Donald A. Risucci
( PDF, 191 KB)
Elaine M. Furmaga, Peter A. Glassman, Francesca E. Cunningham, Chester B. Good
( PDF, 172 KB)
Debra Quinn, Mary Cooper, Lynn Chevalier, Jerry Balentine, Lawrence Kadish, Steven Walerstein, Fredric Weinbaum, Mark Callahan, Eliot Lazar
( PDF, 360 KB)
Pascale Carayon, Ann Schoofs Hundt, Carla J. Alvarado, Scott Springman, Amanda Borgsdorf, Lynn Jenkins
( PDF, 154 KB)
Kathleen A. Harder, John R. Bloomfield, Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush, Jamie S. Sinclair, Mark Kirschbaum, Durand E. Burns
( PDF, 191 KB)
Steven H. Shaha, Linda Brodsky, Michael S. Leonard, Michael A. Cimino, Sandra A. McDougal, Joann M. Pilliod, Kristen E. Martin
( PDF, 175 KB)
Kris Siddharthan, Audrey Nelson, Hope Tiesman, FangFei Chen

Challenges and Lessons Learned

( PDF, 170 KB)
Steven Suydam, Bryan A. Liang, Storm Anderson, Matthew B. Weinger
( PDF, 170 KB)
John D. Banja
(PDF, 190 KB)
Dwight McNeill, Howard Holland, Kerm Henriksen
( PDF, 200 KB)
Richard L. Kravitz, Jonathan D. Neufeld, Michael A. Hogarth, Debora A. Paterniti, William Dager, Richard H. White
( PDF, 183 KB)
Sara J. Singer, Kelly M. Dunham, Jennie D. Bowen, Jeffrey J. Geppert, David M. Gaba, Kathryn M. McDonald, Laurence C. Baker
( PDF, 440 KB)
Heidi B. King, Beth Kohsin, Mary Salisbury
( PDF, 490 KB)
Mary V. Wideman, Michael E. Whittler, Timothy M. Anderson
( PDF, 185 KB)
Deborah G. Graham, Wilson Pace, Jennifer Kappus, Sherry Holcomb, James M. Galliher, Christine W. Duclos, Aaron J. Bonham

Safety Improvement Initiatives

( PDF, 197 KB)
Elizabeth A. P. Vane, Edward Drost, Daryl Elder, Yvonne Heib
( PDF, 403 KB)
Sandra Ludwick
( PDF, 298 KB)
Kimberly J. Rask, Dorothy "Vi" Naylor, Linda Schuessler
( PDF, 253 KB)
Laura Bonner, Bradford Felker, Edmund Chaney, Karen Vollen, Karen Berry, Barbara Revay, Barbara Simon, Lial Kofoed, Scott Ober, Linda Worley, John Fotiades, Scott Sherman
( PDF, 211 KB)
Joel St. Clair

Volume 4. Programs, Tools, and Products (��ƵPublication No. 05-0021-4)

( PDF, 102 KB)
Mary K. Wakefield

Programs and Collaborations

( PDF, 195 KB)
Margaret A. Keyes, Eduardo Ortiz, Deborah Queenan, Ronda Hughes, Francis Chesley, Eileen M. Hogan
( PDF, 191 KB)
Kenneth W. Kizer, Laura N. Blum
( PDF, 225 KB)
Nancy Pratt, Kelly Vo, Theodore G. Ganiats, Matthew B. Weinger
( PDF, 135 KB)
James P. Keller, Jr., Stephen Walker
e ( PDF, 194 KB)
Richard J. Snow, Martin S. Levine, Dwain L. Harper, Sharon L. McGill, George Thomas, Joseph P. McNerney
( PDF, 497 KB)
Dale A. Arroyo

Tools and Procedures

( PDF, 327 KB)
Deborah Carpenter, Veronica Nieva, Tarek Albaghal, Joann Sorra

( PDF, 440 KB; Text Version)

( PDF, 290 KB)
Kimberly A. Galt, Mark V. Siracuse, Ann M. Rule, Bartholomew E. Clark, Wendy Taylor
( PDF, 198 KB)
R. B. Akins
( PDF, 170 KB)
Deborah Gavin-Dreschnack, Lawrence Schonfeld, Audrey Nelson, Stephen Luther
( PDF, 171 KB)
David J. Miranda, Paula K. Zeller, Rosemary Lee, Christopher P. Koepke, Howard E. Holland, Farah Englert, Elaine K. Swift
( PDF, 153 KB)
Myra A. Kleinpeter

Simulation

( PDF, 824 KB)
Marvin P. Fried, Richard Satava, Suzanne Weghorst, Anthony Gallagher, Clarence Sasaki, Douglas Ross, Mika Sinanan, Hernando Cuellar, Jose I. Uribe, Michael Zeltsan, Harman Arora
( PDF, 286 KB)
Pradyumna Dutta, George R. Biltz, Paul E. Johnson, JoAnn M. Sperl-Hillen, William A. Rush, Jane E. Duncan, Patrick J. O'Connor
( PDF, 268 KB)
George Blike, Joseph Cravero, Steve Andeweg, Jens Jensen, Klaus Christoffersen

Education and Training

A ( PDF, 205 KB)
Robert M. Wachter, Kaveh G. Shojania, Tracy Minichiello, Scott A. Flanders, Erin E. Hartman
( PDF, 182 KB)
Suzanne Graham, John Brookey, Catherine Steadman
( PDF, 207 KB)
John R. Meurer, Linda N. Meurer, Jean Grube, Karen J. Brasel, Chris McLaughlin, Stephen Hargarten, Peter M. Layde
( PDF, 243 KB)
David P. Baker, Sigrid Gustafson, J. Mathew Beaubien, Eduardo Salas, Paul Barach
( PDF, 180 KB)
Ben-Tzion Karsh, Pascale Carayon, Maureen Smith, Kathleen Skibinski, Bruce Thomadsen, Patricia Flatley Brennan, Mary Ellen Murray
( PDF, 203 KB)
Nancy E. Donaldson, Rosemary K. Plank, Ann Williamson, Jeffrey Pearl, Jerry Kellogg, Marcia Ryder
( PDF, 714 KB)
Pamela H. Mitchell, Lynne S. Robins, Douglas Schaad
( PDF, 210 KB)
Christel Mottur-Pilson
( PDF, 185 KB)
Rona Patey, Rhona Flin, Georgina Fletcher, Nicola Maran, Ronnie Glavin

Surveillance Tools

( PDF, 197 KB)
Kenneth W. Kizer, Melissa B. Stegun
( PDF, 136 KB)
Quang-Tuyen Nguyen, Joanna Weinberg, Lee H. Hilborne
( PDF, 216 KB)
Ronald A. Nosek, Jr., Judy McMeekin, Geoffrey W. Rake
( PDF, 186 KB)
Lucy A. Savitz, Cheryl B. Jones, Shulamit Bernard
( PDF, 470 KB)
Sandra Meadows, Karen Baker, Jeremy Butler
( PDF, 411 KB)
Kate L. Lapane, Kathleen Cameron, Janice Feinberg

Surveys

( PDF, 190 KB)
Lynne M. Connelly, Judy L. Powers
( PDF, 188 KB)
Mary A. Blegen, Ginette A. Pepper, Joseph Rosse
( PDF, 212 KB)
Ann Schoofs Hundt, Pascale Carayon, Scott Springman, Maureen Smith, Kelly Florek, Rupa Sheth, Margaret Dorshorst
( PDF, 215 KB)
Pascale Carayon, Carla J. Alvarado, Ann Schoofs Hundt, Scott Springman, Amanda Borgsdorf, Peter L.T. Hoonakker
( PDF, 280 KB)
Bonnie J. Wakefield, Tanya Uden-Holman, Douglas S. Wakefield

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