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<br /> S EPTEMBER/OCTOBER 2009<br /> Patient Safety<br /> & QUALITY HEALTHCARE<br /> DIGITAL VERSION<br /> AVAILABLE!<br /> Visit: www.psqh.com/digital<br /> NEWS • SCIENCE • RESEARCH • OPINION<br /> RISK MANAGEMENT<br /> & PATIENT SAFETY<br /> SUICIDE PREVENTION<br /> HEALTHCARE FMEA<br /> JAIL TIME FOR AN ERRORvV<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 98,000 hospital deaths costing more than<br /> $29 billion each year.1 But even one incident costs too much for your<br /> community and your reputation. Reducing medical error requires<br /> understanding of not just adverse events but also near misses.<b<a title="Patient Safety &amp; Quality Healthcare: Risk Management page 1" href="http://viewer.zmags.com/publication/262fa968?page=1"> S EPTEMBER/OCTOBER 2009 Patient Safety & QUALIT</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 2" href="http://viewer.zmags.com/publication/262fa968?page=2"> GE Healthcare The path to reduce medical error st</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 3" href="http://viewer.zmags.com/publication/262fa968?page=3"> When You Leave The Room, We'll Still Be There Mas</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 4" href="http://viewer.zmags.com/publication/262fa968?page=4"> Contents SEPTEMBER/OCTOBER 2009 • VOLUME 6 IS</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 5" href="http://viewer.zmags.com/publication/262fa968?page=5"> SAVE TIME. SAVE LIVES. Central to any healthcare </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 6" href="http://viewer.zmags.com/publication/262fa968?page=6"> </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 7" href="http://viewer.zmags.com/publication/262fa968?page=7"> Patient Safety EDITORIAL ADVISORY BOARD & </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 8" href="http://viewer.zmags.com/publication/262fa968?page=8"> By Michael R. Cohen, RPh, MS, ScD VIEWPOINT An</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 9" href="http://viewer.zmags.com/publication/262fa968?page=9"> Some clinicians will ask, “Why disclose errors an</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 10" href="http://viewer.zmags.com/publication/262fa968?page=10"> By Carolyn M. Clancy, MD AHRQ Patient Safety: </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 11" href="http://viewer.zmags.com/publication/262fa968?page=11"> work—one organization or unit at a time in a heal</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 12" href="http://viewer.zmags.com/publication/262fa968?page=12"> Advances in event reporting. Event report</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 13" href="http://viewer.zmags.com/publication/262fa968?page=13"> BALANCING PAIN MANAGEMENT AND PATIENT SAFETY? YOU</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 14" href="http://viewer.zmags.com/publication/262fa968?page=14"> By Barry P. Chaiken, MD, FHIMSS HEALTH IT & Q</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 15" href="http://viewer.zmags.com/publication/262fa968?page=15"> In the realm of healthcare, patient information e</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 16" href="http://viewer.zmags.com/publication/262fa968?page=16"> from this exchange, brilliant and dedi- cated in</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 17" href="http://viewer.zmags.com/publication/262fa968?page=17"> Jy I rl_ solutions software for safer healthcare </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 18" href="http://viewer.zmags.com/publication/262fa968?page=18"> Risk Management & Patient Safety E </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 19" href="http://viewer.zmags.com/publication/262fa968?page=19"> </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 20" href="http://viewer.zmags.com/publication/262fa968?page=20"> RISK & PATIENT SAFETY vide a vital resourc</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 21" href="http://viewer.zmags.com/publication/262fa968?page=21"> Patient Safety Series Video Library NEW Make yo</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 22" href="http://viewer.zmags.com/publication/262fa968?page=22"> RISK & PATIENT SAFETY </a> <a title="Patient Safety &amp; 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> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 24" href="http://viewer.zmags.com/publication/262fa968?page=24"> RISK & PATIENT SAFETY improve quality of p</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 25" href="http://viewer.zmags.com/publication/262fa968?page=25"> </a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 26" href="http://viewer.zmags.com/publication/262fa968?page=26"> Unit Transformation Improves Safety for Mothers a</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 27" href="http://viewer.zmags.com/publication/262fa968?page=27"> The AHRQ survey and an article by Simpson (20</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 28" href="http://viewer.zmags.com/publication/262fa968?page=28"> ?UNIT TRANSFORMAT ION trained staff to use i</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 29" href="http://viewer.zmags.com/publication/262fa968?page=29"> Elevate Your Patient Safety and Quality Improveme</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 30" href="http://viewer.zmags.com/publication/262fa968?page=30"> UNIT TRANSFORMATION TECHNOLOGY OVERVIEW To im</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 31" href="http://viewer.zmags.com/publication/262fa968?page=31"> PROGRAM DIRECTORS Kevin B.Weiss, MD, MPH Preside</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 32" href="http://viewer.zmags.com/publication/262fa968?page=32"> Healthcare FMEA in the Veterans Health Administra</a> <a title="Patient Safety &amp; Quality Healthcare: Risk Management page 33" href="http://viewer.zmags.com/publication/262fa968?page=33"> safety, production, and design. 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