<br />
S EPTEMBER/OCTOBER 2009<br />
<br />
Patient Safety<br />
& QUALITY HEALTHCARE<br />
<br />
DIGITAL VERSION<br />
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NEWS • SCIENCE • RESEARCH • OPINION<br />
RISK MANAGEMENT<br />
& PATIENT SAFETY<br />
<br />
SUICIDE PREVENTION<br />
HEALTHCARE FMEA<br />
JAIL TIME FOR AN ERRORvV<br />
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<br />
SCIENCE ??? RESEARCH ??? OPINION<br />
& PATIENT SAFETY<br />
SUICIDE PREVENTION<br />
HEALTHCARE FMEA<br />
JAIL TIME FOR AN ERROR<br />
<br />
GE Healthcare<br />
The path to reduce<br />
medical error starts with<br />
understanding near misses.<br />
Patient safety solutions from GE Healthcare. You've seen the numbers<br />
medical error causes up to 98,0<a title="Patient Safety & Quality Healthcare: Risk Management page 1" href="http://viewer.zmags.com/publication/262fa968?page=1">S EPTEMBER/OCTOBER 2009Patient Safety& QUALIT</a> S EPTEMBER/OCTOBER 2009Patient Safety& QUALIT<a title="Patient Safety & Quality Healthcare: Risk Management page 2" href="http://viewer.zmags.com/publication/262fa968?page=2">GE HealthcareThe path to reducemedical error st</a> GE HealthcareThe path to reducemedical error st<a title="Patient Safety & Quality Healthcare: Risk Management page 3" href="http://viewer.zmags.com/publication/262fa968?page=3">When You Leave The Room,We'll Still Be ThereMas</a> When You Leave The Room,We'll Still Be ThereMas<a title="Patient Safety & Quality Healthcare: Risk Management page 4" href="http://viewer.zmags.com/publication/262fa968?page=4">ContentsSEPTEMBER/OCTOBER 2009 • VOLUME 6 IS</a> ContentsSEPTEMBER/OCTOBER 2009 • VOLUME 6 IS<a title="Patient Safety & Quality Healthcare: Risk Management page 5" href="http://viewer.zmags.com/publication/262fa968?page=5">SAVE TIME. SAVE LIVES.Central to any healthcare </a> SAVE TIME. SAVE LIVES.Central to any healthcare <a title="Patient Safety & Quality Healthcare: Risk Management page 6" href="http://viewer.zmags.com/publication/262fa968?page=6"> </a> <a title="Patient Safety & Quality Healthcare: Risk Management page 7" href="http://viewer.zmags.com/publication/262fa968?page=7">Patient Safety EDITORIAL ADVISORY BOARD& </a> Patient Safety EDITORIAL ADVISORY BOARD& <a title="Patient Safety & Quality Healthcare: Risk Management page 8" href="http://viewer.zmags.com/publication/262fa968?page=8">By Michael R. Cohen, RPh, MS, ScDVIEWPOINTAn</a> By Michael R. Cohen, RPh, MS, ScDVIEWPOINTAn<a title="Patient Safety & Quality Healthcare: Risk Management page 9" href="http://viewer.zmags.com/publication/262fa968?page=9">Some clinicians will ask,“Why disclose errors an</a> Some clinicians will ask,“Why disclose errors an<a title="Patient Safety & Quality Healthcare: Risk Management page 10" href="http://viewer.zmags.com/publication/262fa968?page=10">By Carolyn M. Clancy, MDAHRQPatient Safety:</a> By Carolyn M. Clancy, MDAHRQPatient Safety:<a title="Patient Safety & Quality Healthcare: Risk Management page 11" href="http://viewer.zmags.com/publication/262fa968?page=11">work—one organization or unit at a timein a heal</a> work—one organization or unit at a timein a heal<a title="Patient Safety & Quality Healthcare: Risk Management page 12" href="http://viewer.zmags.com/publication/262fa968?page=12"> Advances in event reporting. Eventreport</a> Advances in event reporting. Eventreport<a title="Patient Safety & Quality Healthcare: Risk Management page 13" href="http://viewer.zmags.com/publication/262fa968?page=13">BALANCING PAIN MANAGEMENT AND PATIENT SAFETY?YOU</a> BALANCING PAIN MANAGEMENT AND PATIENT SAFETY?YOU<a title="Patient Safety & Quality Healthcare: Risk Management page 14" href="http://viewer.zmags.com/publication/262fa968?page=14">By Barry P. Chaiken, MD, FHIMSSHEALTH IT & Q</a> By Barry P. Chaiken, MD, FHIMSSHEALTH IT & Q<a title="Patient Safety & Quality Healthcare: Risk Management page 15" href="http://viewer.zmags.com/publication/262fa968?page=15">In the realm of healthcare,patient informatione</a> In the realm of healthcare,patient informatione<a title="Patient Safety & Quality Healthcare: Risk Management page 16" href="http://viewer.zmags.com/publication/262fa968?page=16">from this exchange, brilliant and dedi-cated in</a> from this exchange, brilliant and dedi-cated in<a title="Patient Safety & Quality Healthcare: Risk Management page 17" href="http://viewer.zmags.com/publication/262fa968?page=17">JyIrl_ solutionssoftware for safer healthcare</a> JyIrl_ solutionssoftware for safer healthcare<a title="Patient Safety & Quality Healthcare: Risk Management page 18" href="http://viewer.zmags.com/publication/262fa968?page=18">Risk Management& Patient SafetyE </a> Risk Management& Patient SafetyE <a title="Patient Safety & Quality Healthcare: Risk Management page 19" href="http://viewer.zmags.com/publication/262fa968?page=19"> </a> <a title="Patient Safety & Quality Healthcare: Risk Management page 20" href="http://viewer.zmags.com/publication/262fa968?page=20"> RISK & PATIENT SAFETYvide a vital resourc</a> RISK & PATIENT SAFETYvide a vital resourc<a title="Patient Safety & Quality Healthcare: Risk Management page 21" href="http://viewer.zmags.com/publication/262fa968?page=21">Patient Safety Series Video LibraryNEWMake yo</a> Patient Safety Series Video LibraryNEWMake yo<a title="Patient Safety & Quality Healthcare: Risk Management page 22" href="http://viewer.zmags.com/publication/262fa968?page=22"> RISK & PATIENT SAFETY </a> RISK & PATIENT SAFETY <a title="Patient Safety & Quality Healthcare: Risk Management page 23" href="http://viewer.zmags.com/publication/262fa968?page=23">Get the Upper Hand on Patient Safety.Sigma Spect</a> Get the Upper Hand on Patient Safety.Sigma Spect<a title="Patient Safety & Quality Healthcare: Risk Management page 24" href="http://viewer.zmags.com/publication/262fa968?page=24"> RISK & PATIENT SAFETYimprove quality of p</a> RISK & PATIENT SAFETYimprove quality of p<a title="Patient Safety & Quality Healthcare: Risk Management page 25" href="http://viewer.zmags.com/publication/262fa968?page=25"> </a> <a title="Patient Safety & Quality Healthcare: Risk Management page 26" href="http://viewer.zmags.com/publication/262fa968?page=26">Unit TransformationImproves Safetyfor Mothers a</a> Unit TransformationImproves Safetyfor Mothers a<a title="Patient Safety & Quality Healthcare: Risk Management page 27" href="http://viewer.zmags.com/publication/262fa968?page=27"> The AHRQ survey and an article bySimpson (20</a> The AHRQ survey and an article bySimpson (20<a title="Patient Safety & Quality Healthcare: Risk Management page 28" href="http://viewer.zmags.com/publication/262fa968?page=28"> ?UNIT TRANSFORMATIONtrained staff to use i</a> ?UNIT TRANSFORMATIONtrained staff to use i<a title="Patient Safety & Quality Healthcare: Risk Management page 29" href="http://viewer.zmags.com/publication/262fa968?page=29">Elevate Your Patient Safety andQuality Improveme</a> Elevate Your Patient Safety andQuality Improveme<a title="Patient Safety & Quality Healthcare: Risk Management page 30" href="http://viewer.zmags.com/publication/262fa968?page=30"> UNIT TRANSFORMATIONTECHNOLOGY OVERVIEWTo im</a> UNIT TRANSFORMATIONTECHNOLOGY OVERVIEWTo im<a title="Patient Safety & Quality Healthcare: Risk Management page 31" href="http://viewer.zmags.com/publication/262fa968?page=31">PROGRAM DIRECTORSKevin B.Weiss, MD, MPHPreside</a> PROGRAM DIRECTORSKevin B.Weiss, MD, MPHPreside<a title="Patient Safety & Quality Healthcare: Risk Management page 32" href="http://viewer.zmags.com/publication/262fa968?page=32">Healthcare FMEAin theVeterans HealthAdministra</a> Healthcare FMEAin theVeterans HealthAdministra<a title="Patient Safety & Quality Healthcare: Risk Management page 33" href="http://viewer.zmags.com/publication/262fa968?page=33">safety, production, and design. Adapting FMEA to</a> safety, production, and design. Adapting FMEA to<a title="Patient Safety & Quality Healthcare: Risk Management page 34" href="http://viewer.zmags.com/publication/262fa968?page=34"> HEALTHCARE FMEA </a> HEALTHCARE FMEA <a title="Patient Safety & Quality Healthcare: Risk Management page 35" href="http://viewer.zmags.com/publication/262fa968?page=35">About NCPSHeadquartered in Ann Arbor, Michigan, </a> About NCPSHeadquartered in Ann Arbor, Michigan, <a title="Patient Safety & Quality Healthcare: Risk Management page 36" href="http://viewer.zmags.com/publication/262fa968?page=36">Suicide PreventionOutside thePsychiatry Departm</a> Suicide PreventionOutside thePsychiatry Departm<a title="Patient Safety & Quality Healthcare: Risk Management page 37" href="http://viewer.zmags.com/publication/262fa968?page=37">found of inpatient suicides that occurred in gene</a> found of inpatient suicides that occurred in gene<a title="Patient Safety & Quality Healthcare: Risk Management page 38" href="http://viewer.zmags.com/publication/262fa968?page=38"> SUICIDE PREVENTIONCUSTOMIZED </a> SUICIDE PREVENTIONCUSTOMIZED <a title="Patient Safety & Quality Healthcare: Risk Management page 39" href="http://viewer.zmags.com/publication/262fa968?page=39">emergency nurse observes the patient at a minimum</a> emergency nurse observes the patient at a minimum<a title="Patient Safety & Quality Healthcare: Risk Management page 40" href="http://viewer.zmags.com/publication/262fa968?page=40"> SUICIDE PREVENTION </a> SUICIDE PREVENTION <a title="Patient Safety & Quality Healthcare: Risk Management page 41" href="http://viewer.zmags.com/publication/262fa968?page=41"> ThNeaNtiointahl QUALITYCOLLOQUIUMON</a> ThNeaNtiointahl QUALITYCOLLOQUIUMON<a title="Patient Safety & Quality Healthcare: Risk Management page 42" href="http://viewer.zmags.com/publication/262fa968?page=42">SUICIDE PREVENTIONfor the intended populati</a> SUICIDE PREVENTIONfor the intended populati<a title="Patient Safety & Quality Healthcare: Risk Management page 43" href="http://viewer.zmags.com/publication/262fa968?page=43">$efficiencyretentioninnovation%lead</a> $efficiencyretentioninnovation%lead<a title="Patient Safety & Quality Healthcare: Risk Management page 44" href="http://viewer.zmags.com/publication/262fa968?page=44">IT Integrationin the ORA CASE STUDY FOR IMPROV</a> IT Integrationin the ORA CASE STUDY FOR IMPROV<a title="Patient Safety & Quality Healthcare: Risk Management page 45" href="http://viewer.zmags.com/publication/262fa968?page=45">ability between the hospital’s supply dispensing </a> ability between the hospital’s supply dispensing <a title="Patient Safety & Quality Healthcare: Risk Management page 46" href="http://viewer.zmags.com/publication/262fa968?page=46"> IT INTEGRATIONwere concerned about electr</a> IT INTEGRATIONwere concerned about electr<a title="Patient Safety & Quality Healthcare: Risk Management page 47" href="http://viewer.zmags.com/publication/262fa968?page=47">In the OR, every minute counts.Pyxis® Periopera</a> In the OR, every minute counts.Pyxis® Periopera<a title="Patient Safety & Quality Healthcare: Risk Management page 48" href="http://viewer.zmags.com/publication/262fa968?page=48"> IT INTEGRATIONintegration are very meanin</a> IT INTEGRATIONintegration are very meanin<a title="Patient Safety & Quality Healthcare: Risk Management page 49" href="http://viewer.zmags.com/publication/262fa968?page=49">Predict.Prevent.Protect.Joint Commission Resou</a> Predict.Prevent.Protect.Joint Commission Resou<a title="Patient Safety & Quality Healthcare: Risk Management page 50" href="http://viewer.zmags.com/publication/262fa968?page=50"> IT INTEGRATIONManager,”whereas in the old</a> IT INTEGRATIONManager,”whereas in the old<a title="Patient Safety & Quality Healthcare: Risk Management page 51" href="http://viewer.zmags.com/publication/262fa968?page=51">Facility orice/AmbulatoryProgramsDemands on st</a> Facility orice/AmbulatoryProgramsDemands on st<a title="Patient Safety & Quality Healthcare: Risk Management page 52" href="http://viewer.zmags.com/publication/262fa968?page=52">By Karen Wolk Feinstein, PhDPERSPECTIVEEnfo</a> By Karen Wolk Feinstein, PhDPERSPECTIVEEnfo<a title="Patient Safety & Quality Healthcare: Risk Management page 53" href="http://viewer.zmags.com/publication/262fa968?page=53">able information collected by existingpublic and</a> able information collected by existingpublic and<a title="Patient Safety & Quality Healthcare: Risk Management page 54" href="http://viewer.zmags.com/publication/262fa968?page=54">ABQAURPLAST CHANCE TO REGISTER FOR THIS YEAR’S A</a> ABQAURPLAST CHANCE TO REGISTER FOR THIS YEAR’S A<a title="Patient Safety & Quality Healthcare: Risk Management page 55" href="http://viewer.zmags.com/publication/262fa968?page=55">ABQAURPNEWS </a> ABQAURPNEWS <a title="Patient Safety & Quality Healthcare: Risk Management page 56" href="http://viewer.zmags.com/publication/262fa968?page=56">In an era when Congress and Americanconsumers ar</a> In an era when Congress and Americanconsumers ar<a title="Patient Safety & Quality Healthcare: Risk Management page 57" href="http://viewer.zmags.com/publication/262fa968?page=57">Message from the Chairand announcements. Other </a> Message from the Chairand announcements. Other <a title="Patient Safety & Quality Healthcare: Risk Management page 58" href="http://viewer.zmags.com/publication/262fa968?page=58">Patient Safety and Quality Healthcare (PSQH)welc</a> Patient Safety and Quality Healthcare (PSQH)welc<a title="Patient Safety & Quality Healthcare: Risk Management page 59" href="http://viewer.zmags.com/publication/262fa968?page=59">mmPeer Reuiew: The Fundamental Background ofDua</a> mmPeer Reuiew: The Fundamental Background ofDua<a title="Patient Safety & Quality Healthcare: Risk Management page 60" href="http://viewer.zmags.com/publication/262fa968?page=60">Learn how our Safety CultureSolution can help yo</a> Learn how our Safety CultureSolution can help yo