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<br /> N OVEMBER/DECEMBER 2009<br /> Patient Safety<br /> & QUALITY HEALTHCARE<br /> DIGITAL VERSION<br /> AVAILABLE!<br /> Visit: www.psqh.com/digital<br /> NEWS • SCIENCE • RESEARCH • OPINION<br /> ADVANCING<br /> PATIENT SAFETY<br /> IMPROVING<br /> SURGICAL QUALITY<br /> COMPARATIVE EFFECTIVENESS<br /> FALL PREVENTIONPatient Safety<br /> & Q.UALLVY Lil??/A.LVLiC/Ull??<br /> ?? VI 5 ' j. C J i<br /> ???????!??MirMiW Ul H lil<br /> %,<br /> IMPROVING<br /> SURGICAL QUALITY<br /> MF -RATIVE EFFECTIVENESS<br /> FALL PREVENTION<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 <a title="Patient Safety &amp; Quality Healthcare page 1" href="http://viewer.zmags.com/publication/4700a328?page=1"> N OVEMBER/DECEMBER 2009 Patient Safety & QUALIT</a> <a title="Patient Safety &amp; Quality Healthcare page 2" href="http://viewer.zmags.com/publication/4700a328?page=2"> GE Healthcare The path to reduce medical error st</a> <a title="Patient Safety &amp; Quality Healthcare page 3" href="http://viewer.zmags.com/publication/4700a328?page=3"> When You Leave The Room, We’ll Still Be There </a> <a title="Patient Safety &amp; Quality Healthcare page 4" href="http://viewer.zmags.com/publication/4700a328?page=4"> Contents NOVEMBER/DECEMBER 2009 • VOLUME 6 IS</a> <a title="Patient Safety &amp; Quality Healthcare page 5" href="http://viewer.zmags.com/publication/4700a328?page=5"> SAVE TIME. SAVE LIVES. Central to any healthcare </a> <a title="Patient Safety &amp; Quality Healthcare page 6" href="http://viewer.zmags.com/publication/4700a328?page=6"> </a> <a title="Patient Safety &amp; Quality Healthcare page 7" href="http://viewer.zmags.com/publication/4700a328?page=7"> Patient Safety EDITORIAL ADVISORY BOARD & </a> <a title="Patient Safety &amp; Quality Healthcare page 8" href="http://viewer.zmags.com/publication/4700a328?page=8"> By Carolyn M. Clancy, MD AHRQ Comparative Effe</a> <a title="Patient Safety &amp; Quality Healthcare page 9" href="http://viewer.zmags.com/publication/4700a328?page=9"> Since the program’s inception, it has pub</a> <a title="Patient Safety &amp; Quality Healthcare page 10" href="http://viewer.zmags.com/publication/4700a328?page=10"> gram. The transparency begins with an open proces</a> <a title="Patient Safety &amp; Quality Healthcare page 11" href="http://viewer.zmags.com/publication/4700a328?page=11"> Patient Safety Series Video Library NEW Make yo</a> <a title="Patient Safety &amp; Quality Healthcare page 12" href="http://viewer.zmags.com/publication/4700a328?page=12"> By Barry P. Chaiken, MD, FHIMSS HEALTH IT & Q</a> <a title="Patient Safety &amp; Quality Healthcare page 13" href="http://viewer.zmags.com/publication/4700a328?page=13"> R </a> <a title="Patient Safety &amp; Quality Healthcare page 14" href="http://viewer.zmags.com/publication/4700a328?page=14"> By Steve Elder NEVER EVENTS Rhode Island Hos</a> <a title="Patient Safety &amp; Quality Healthcare page 15" href="http://viewer.zmags.com/publication/4700a328?page=15"> “What makes fall manage- ment so difficult is tha</a> <a title="Patient Safety &amp; Quality Healthcare page 16" href="http://viewer.zmags.com/publication/4700a328?page=16"> T O </a> <a title="Patient Safety &amp; Quality Healthcare page 17" href="http://viewer.zmags.com/publication/4700a328?page=17"> Get the Upper Hand on Patient Safety. Sigma Spect</a> <a title="Patient Safety &amp; Quality Healthcare page 18" href="http://viewer.zmags.com/publication/4700a328?page=18"> Transform Your It's about culture. RWD fosters th</a> <a title="Patient Safety &amp; Quality Healthcare page 19" href="http://viewer.zmags.com/publication/4700a328?page=19"> SUPPLEMENT TO PATIENT SAFETY & QUALITY HEALTHCARE</a> <a title="Patient Safety &amp; Quality Healthcare page 20" href="http://viewer.zmags.com/publication/4700a328?page=20"> How a Captive Insurer Uses Data and Incentiv</a> <a title="Patient Safety &amp; Quality Healthcare page 21" href="http://viewer.zmags.com/publication/4700a328?page=21"> T he Institute of M</a> <a title="Patient Safety &amp; Quality Healthcare page 22" href="http://viewer.zmags.com/publication/4700a328?page=22"> ADVANCING PATIENT SAFETY with a unifying c</a> <a title="Patient Safety &amp; Quality Healthcare page 23" href="http://viewer.zmags.com/publication/4700a328?page=23"> With an average of 15 sepsis patients per month, </a> <a title="Patient Safety &amp; Quality Healthcare page 24" href="http://viewer.zmags.com/publication/4700a328?page=24"> ADVANCING PATIENT SAFETY change. We’d like </a> <a title="Patient Safety &amp; Quality Healthcare page 25" href="http://viewer.zmags.com/publication/4700a328?page=25"> Many CRICO-insured hospitals have embedded </a> <a title="Patient Safety &amp; Quality Healthcare page 26" href="http://viewer.zmags.com/publication/4700a328?page=26"> ADVANCING PATIENT SAFETY had participated</a> <a title="Patient Safety &amp; Quality Healthcare page 27" href="http://viewer.zmags.com/publication/4700a328?page=27"> 0;5:3 ;A> <->@ MAKINGTHECASEFOR PATIENTSAFETY N </a> <a title="Patient Safety &amp; Quality Healthcare page 28" href="http://viewer.zmags.com/publication/4700a328?page=28"> ADVANCING PATIENT SAFETY SIX TIPS FOR SUCCESSF</a> <a title="Patient Safety &amp; Quality Healthcare page 29" href="http://viewer.zmags.com/publication/4700a328?page=29"> Jy I rl_ solutions software for safer healthcare </a> <a title="Patient Safety &amp; Quality Healthcare page 30" href="http://viewer.zmags.com/publication/4700a328?page=30"> RAPID RESPONSE TEAMS AND Continuous Quality Imp</a> <a title="Patient Safety &amp; Quality Healthcare page 31" href="http://viewer.zmags.com/publication/4700a328?page=31"> </a> <a title="Patient Safety &amp; Quality Healthcare page 32" href="http://viewer.zmags.com/publication/4700a328?page=32"> RAPID RESPONSE TEAMS Figure 2 represent</a> <a title="Patient Safety &amp; Quality Healthcare page 33" href="http://viewer.zmags.com/publication/4700a328?page=33"> Additionally, the team has noted a downward tr</a> <a title="Patient Safety &amp; Quality Healthcare page 34" href="http://viewer.zmags.com/publication/4700a328?page=34"> MEDWISE: Preventing Medication Waste While Promo</a> <a title="Patient Safety &amp; Quality Healthcare page 35" href="http://viewer.zmags.com/publication/4700a328?page=35"> dence of tampering may be returned to stock. On t</a> <a title="Patient Safety &amp; Quality Healthcare page 36" href="http://viewer.zmags.com/publication/4700a328?page=36"> PREVENTING MEDICATION WASTE informati</a> <a title="Patient Safety &amp; Quality Healthcare page 37" href="http://viewer.zmags.com/publication/4700a328?page=37"> Currently, we are in the implementation ph</a> <a title="Patient Safety &amp; Quality Healthcare page 38" href="http://viewer.zmags.com/publication/4700a328?page=38"> MEASURING AND IMPROVING Surgical Quality O </a> <a title="Patient Safety &amp; Quality Healthcare page 39" href="http://viewer.zmags.com/publication/4700a328?page=39"> are to improve healthcare by establishing Given</a> <a title="Patient Safety &amp; Quality Healthcare page 40" href="http://viewer.zmags.com/publication/4700a328?page=40"> SURGICAL QUALITY and of itself, routinely </a> <a title="Patient Safety &amp; Quality Healthcare page 41" href="http://viewer.zmags.com/publication/4700a328?page=41"> collected by a third party specifically trained a</a> <a title="Patient Safety &amp; Quality Healthcare page 42" href="http://viewer.zmags.com/publication/4700a328?page=42"> SURGICAL QUALITY QCluinailcitayl,IOs Luto</a> <a title="Patient Safety &amp; Quality Healthcare page 43" href="http://viewer.zmags.com/publication/4700a328?page=43"> achieved 11 to 17% improvement in quality each ye</a> <a title="Patient Safety &amp; Quality Healthcare page 44" href="http://viewer.zmags.com/publication/4700a328?page=44"> ADVANCING THE PRACTICE OF EVIDENCE-BASED MEDICINE</a> <a title="Patient Safety &amp; Quality Healthcare page 45" href="http://viewer.zmags.com/publication/4700a328?page=45"> Heightened regulatory oversight and </a> <a title="Patient Safety &amp; Quality Healthcare page 46" href="http://viewer.zmags.com/publication/4700a328?page=46"> STANDARDIZED ORDER SETS ORLANDO HEALTH LOOKS T</a> <a title="Patient Safety &amp; Quality Healthcare page 47" href="http://viewer.zmags.com/publication/4700a328?page=47"> Elevate Your Patient Safety and Quality Improveme</a> <a title="Patient Safety &amp; Quality Healthcare page 48" href="http://viewer.zmags.com/publication/4700a328?page=48"> STANDARDIZED ORDER SETS care, order sets ap</a> <a title="Patient Safety &amp; Quality Healthcare page 49" href="http://viewer.zmags.com/publication/4700a328?page=49"> NPSF National Patient Safety Foundation* asm mm</a> <a title="Patient Safety &amp; Quality Healthcare page 50" href="http://viewer.zmags.com/publication/4700a328?page=50"> Alicia Appel, MD Thomas Mackenzie, MD, MSPH, FAC </a> <a title="Patient Safety &amp; Quality Healthcare page 51" href="http://viewer.zmags.com/publication/4700a328?page=51"> Patient Name: Medical Record Number: {pt mrn} D</a> <a title="Patient Safety &amp; Quality Healthcare page 52" href="http://viewer.zmags.com/publication/4700a328?page=52"> By Mike Olive and Mike Brown TOYOTA PRODUCTION </a> <a title="Patient Safety &amp; Quality Healthcare page 53" href="http://viewer.zmags.com/publication/4700a328?page=53"> HUMAN CENTERED BEHAVIOR The fo</a> <a title="Patient Safety &amp; Quality Healthcare page 54" href="http://viewer.zmags.com/publication/4700a328?page=54"> In every aspect of the delivery of care, clear e</a> <a title="Patient Safety &amp; Quality Healthcare page 55" href="http://viewer.zmags.com/publication/4700a328?page=55"> PROGRAM DIRECTORS Kevin B.Weiss, MD, MPH Preside</a> <a title="Patient Safety &amp; Quality Healthcare page 56" href="http://viewer.zmags.com/publication/4700a328?page=56"> PULSE AHRQ to Expand Implementation of CUSP Ac</a> <a title="Patient Safety &amp; Quality Healthcare page 57" href="http://viewer.zmags.com/publication/4700a328?page=57"> Color-coded labels help ensure the correct produc</a> <a title="Patient Safety &amp; Quality Healthcare page 58" href="http://viewer.zmags.com/publication/4700a328?page=58"> “The opportunity to establish an interdisci</a> <a title="Patient Safety &amp; Quality Healthcare page 59" href="http://viewer.zmags.com/publication/4700a328?page=59"> 'BMMQSFWFOUJPOJTOPU POMZQPTTJCMF‰JUTQSPWFO *OUPE</a> <a title="Patient Safety &amp; Quality Healthcare page 60" href="http://viewer.zmags.com/publication/4700a328?page=60"> TRENDS First DataBank Joins Health 2.0 Acceler</a> <a title="Patient Safety &amp; Quality Healthcare page 61" href="http://viewer.zmags.com/publication/4700a328?page=61"> ThNeaNtiointahl QUALITY COLLOQUIUM ON</a> <a title="Patient Safety &amp; Quality Healthcare page 62" href="http://viewer.zmags.com/publication/4700a328?page=62"> ABQAURPPILOT PROGRAM FOR MENTORS A SUCCESS The </a> <a title="Patient Safety &amp; Quality Healthcare page 63" href="http://viewer.zmags.com/publication/4700a328?page=63"> ABQAURP NEWS </a> <a title="Patient Safety &amp; Quality Healthcare page 64" href="http://viewer.zmags.com/publication/4700a328?page=64"> Healthcare has accounted for over 50% of the Bald</a> <a title="Patient Safety &amp; Quality Healthcare page 65" href="http://viewer.zmags.com/publication/4700a328?page=65"> Greetings from the Chair The past two months hav</a> <a title="Patient Safety &amp; Quality Healthcare page 66" href="http://viewer.zmags.com/publication/4700a328?page=66"> Patient Safety and Quality Healthcare (PSQH) welc</a> <a title="Patient Safety &amp; Quality Healthcare page 67" href="http://viewer.zmags.com/publication/4700a328?page=67"> unnecessary servic examinatii (NBME) testing expe</a> <a title="Patient Safety &amp; Quality Healthcare page 68" href="http://viewer.zmags.com/publication/4700a328?page=68"> Learn how our Safety Culture Solution can help yo</a>