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<br /> J ULY/AUGUST 2009<br /> <br /> Patient Safety<br /> & QUALITY HEALTHCARE<br /> <br /> DIGITAL VERSION<br /> AVAILABLE!<br /> Visit: www.psqh.com/digital<br /> <br /> NEWS • SCIENCE • RESEARCH • OPINION<br /> MEDICATION SAFETY<br /> TECHNOLOGIES<br /> <br /> BIOMEDICAL DEVICE<br /> INTEGRATION<br /> PATIENT SAFETY COUNCILS<br /> HIGH-ALERT MEDICATIONS<br /> <br /> <br /> Contents<br /> JULY/AUGUST 2009 • VOLUME 6 ISSUE 4<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> Features<br /> <br /> 22 MEDICATION SAFETY TECHNOLOGIES:<br /> WHAT IS AND IS NOT WORKING<br /> David W. Bates, MD, MSc; Robert M. Wachter, MD;<br /> Tim Vanderve<a title="Patient Safety & Quality Healthcare page 1" href="http://viewer.zmags.com/publication/bc60bbb8?page=1">J ULY/AUGUST 2009Patient Safety& QUALITY HEAL</a> J ULY/AUGUST 2009Patient Safety& QUALITY HEAL<a title="Patient Safety & Quality Healthcare page 2" href="http://viewer.zmags.com/publication/bc60bbb8?page=2"></a> <a title="Patient Safety & Quality Healthcare page 3" href="http://viewer.zmags.com/publication/bc60bbb8?page=3"></a> <a title="Patient Safety & Quality Healthcare page 4" href="http://viewer.zmags.com/publication/bc60bbb8?page=4">ContentsJULY/AUGUST 2009 • VOLUME 6 ISSUE </a> ContentsJULY/AUGUST 2009 • VOLUME 6 ISSUE <a title="Patient Safety & Quality Healthcare page 5" href="http://viewer.zmags.com/publication/bc60bbb8?page=5"></a> <a title="Patient Safety & Quality Healthcare page 6" href="http://viewer.zmags.com/publication/bc60bbb8?page=6"> </a> <a title="Patient Safety & Quality Healthcare page 7" href="http://viewer.zmags.com/publication/bc60bbb8?page=7">Patient Safety EDITORIAL ADVISORY BOARD& </a> Patient Safety EDITORIAL ADVISORY BOARD& <a title="Patient Safety & Quality Healthcare page 8" href="http://viewer.zmags.com/publication/bc60bbb8?page=8">LETTERSIs Heparin Therapy Outmoded?To t</a> LETTERSIs Heparin Therapy Outmoded?To t<a title="Patient Safety & Quality Healthcare page 9" href="http://viewer.zmags.com/publication/bc60bbb8?page=9">in others, unfractionated heparin.Despite all</a> in others, unfractionated heparin.Despite all<a title="Patient Safety & Quality Healthcare page 10" href="http://viewer.zmags.com/publication/bc60bbb8?page=10">By Carolyn M. Clancy, MDAHRQPatient Safety C</a> By Carolyn M. Clancy, MDAHRQPatient Safety C<a title="Patient Safety & Quality Healthcare page 11" href="http://viewer.zmags.com/publication/bc60bbb8?page=11">Community-based Patient Safety AdvisoryCouncil (</a> Community-based Patient Safety AdvisoryCouncil (<a title="Patient Safety & Quality Healthcare page 12" href="http://viewer.zmags.com/publication/bc60bbb8?page=12"> agreeing to address all council members</a> agreeing to address all council members<a title="Patient Safety & Quality Healthcare page 13" href="http://viewer.zmags.com/publication/bc60bbb8?page=13">BALANCING PAIN MANAGEMENT AND PATIENT SAFETY?YOU</a> BALANCING PAIN MANAGEMENT AND PATIENT SAFETY?YOU<a title="Patient Safety & Quality Healthcare page 14" href="http://viewer.zmags.com/publication/bc60bbb8?page=14">By Barry P. Chaiken, MD, FHIMSSQ&AState of t</a> By Barry P. Chaiken, MD, FHIMSSQ&AState of t<a title="Patient Safety & Quality Healthcare page 15" href="http://viewer.zmags.com/publication/bc60bbb8?page=15">Clinical problem solversare a heterogeneousgrou</a> Clinical problem solversare a heterogeneousgrou<a title="Patient Safety & Quality Healthcare page 16" href="http://viewer.zmags.com/publication/bc60bbb8?page=16"> The other report that I hopeCongress and </a> The other report that I hopeCongress and <a title="Patient Safety & Quality Healthcare page 17" href="http://viewer.zmags.com/publication/bc60bbb8?page=17">$efficiencyretentioninnovation%lead</a> $efficiencyretentioninnovation%lead<a title="Patient Safety & Quality Healthcare page 18" href="http://viewer.zmags.com/publication/bc60bbb8?page=18">By Ali Rashidee, MD, MS; Juliana Hart, BSN, MPH, </a> By Ali Rashidee, MD, MS; Juliana Hart, BSN, MPH, <a title="Patient Safety & Quality Healthcare page 19" href="http://viewer.zmags.com/publication/bc60bbb8?page=19">tion errors were reported from approxi-mately 53</a> tion errors were reported from approxi-mately 53<a title="Patient Safety & Quality Healthcare page 20" href="http://viewer.zmags.com/publication/bc60bbb8?page=20">Figure 2. High-Alert Medication Errors for Drugs </a> Figure 2. High-Alert Medication Errors for Drugs <a title="Patient Safety & Quality Healthcare page 21" href="http://viewer.zmags.com/publication/bc60bbb8?page=21">Figure 3. High-Alert Medication Errors by Admini</a> Figure 3. High-Alert Medication Errors by Admini<a title="Patient Safety & Quality Healthcare page 22" href="http://viewer.zmags.com/publication/bc60bbb8?page=22"></a> <a title="Patient Safety & Quality Healthcare page 23" href="http://viewer.zmags.com/publication/bc60bbb8?page=23"></a> <a title="Patient Safety & Quality Healthcare page 24" href="http://viewer.zmags.com/publication/bc60bbb8?page=24">MEDICATION SAFETY TECHNOLOGIES:What Is andIs </a> MEDICATION SAFETY TECHNOLOGIES:What Is andIs <a title="Patient Safety & Quality Healthcare page 25" href="http://viewer.zmags.com/publication/bc60bbb8?page=25">little by little, but it’s harder than I think pe</a> little by little, but it’s harder than I think pe<a title="Patient Safety & Quality Healthcare page 26" href="http://viewer.zmags.com/publication/bc60bbb8?page=26">MEDICATION SAFETY TECHNOLOGIESbecause they</a> MEDICATION SAFETY TECHNOLOGIESbecause they<a title="Patient Safety & Quality Healthcare page 27" href="http://viewer.zmags.com/publication/bc60bbb8?page=27">adverse drug events were preventable. Especially </a> adverse drug events were preventable. Especially <a title="Patient Safety & Quality Healthcare page 28" href="http://viewer.zmags.com/publication/bc60bbb8?page=28">MEDICATION SAFETY TECHNOLOGIES I do t</a> MEDICATION SAFETY TECHNOLOGIES I do t<a title="Patient Safety & Quality Healthcare page 29" href="http://viewer.zmags.com/publication/bc60bbb8?page=29">dictable. There is recognition now that there is </a> dictable. There is recognition now that there is <a title="Patient Safety & Quality Healthcare page 30" href="http://viewer.zmags.com/publication/bc60bbb8?page=30">Biomedical Device IntegrationThe Impact o</a> Biomedical Device IntegrationThe Impact o<a title="Patient Safety & Quality Healthcare page 31" href="http://viewer.zmags.com/publication/bc60bbb8?page=31">HImage © Sabrih | Dreamstime.com </a> HImage © Sabrih | Dreamstime.com <a title="Patient Safety & Quality Healthcare page 32" href="http://viewer.zmags.com/publication/bc60bbb8?page=32">BIOMEDICAL DEVICE INTEGRATIONwireless devi</a> BIOMEDICAL DEVICE INTEGRATIONwireless devi<a title="Patient Safety & Quality Healthcare page 33" href="http://viewer.zmags.com/publication/bc60bbb8?page=33">it is essential that hospitals carefully consider</a> it is essential that hospitals carefully consider<a title="Patient Safety & Quality Healthcare page 34" href="http://viewer.zmags.com/publication/bc60bbb8?page=34">BIOMEDICAL DEVICE INTEGRATIONclinician fir</a> BIOMEDICAL DEVICE INTEGRATIONclinician fir<a title="Patient Safety & Quality Healthcare page 35" href="http://viewer.zmags.com/publication/bc60bbb8?page=35"> QUALITY The Eig</a> QUALITY The Eig<a title="Patient Safety & Quality Healthcare page 36" href="http://viewer.zmags.com/publication/bc60bbb8?page=36">TESTS OF CHANGE:Simulated Design ofExperiment</a> TESTS OF CHANGE:Simulated Design ofExperiment<a title="Patient Safety & Quality Healthcare page 37" href="http://viewer.zmags.com/publication/bc60bbb8?page=37">typically involves factors that are less easily q</a> typically involves factors that are less easily q<a title="Patient Safety & Quality Healthcare page 38" href="http://viewer.zmags.com/publication/bc60bbb8?page=38"> SIMULATED DESIGN3. Inputs. Number of RNs </a> SIMULATED DESIGN3. Inputs. Number of RNs <a title="Patient Safety & Quality Healthcare page 39" href="http://viewer.zmags.com/publication/bc60bbb8?page=39">(2a) Interaction Plot for LOS(2</a> (2a) Interaction Plot for LOS(2<a title="Patient Safety & Quality Healthcare page 40" href="http://viewer.zmags.com/publication/bc60bbb8?page=40"> SIMULATED DESIGNmodel is created, scenari</a> SIMULATED DESIGNmodel is created, scenari<a title="Patient Safety & Quality Healthcare page 41" href="http://viewer.zmags.com/publication/bc60bbb8?page=41">A Comprehensive Guide to Managing Never Ev</a> A Comprehensive Guide to Managing Never Ev<a title="Patient Safety & Quality Healthcare page 42" href="http://viewer.zmags.com/publication/bc60bbb8?page=42">EHR SupportsHealthier Patientsand a HealthierB</a> EHR SupportsHealthier Patientsand a HealthierB<a title="Patient Safety & Quality Healthcare page 43" href="http://viewer.zmags.com/publication/bc60bbb8?page=43">maximize the value of the technology and to </a> maximize the value of the technology and to <a title="Patient Safety & Quality Healthcare page 44" href="http://viewer.zmags.com/publication/bc60bbb8?page=44"> EHR SUPPORTS</a> EHR SUPPORTS<a title="Patient Safety & Quality Healthcare page 45" href="http://viewer.zmags.com/publication/bc60bbb8?page=45"></a> <a title="Patient Safety & Quality Healthcare page 46" href="http://viewer.zmags.com/publication/bc60bbb8?page=46">ABQAURPABQAURP is the only Health Care Qualit</a> ABQAURPABQAURP is the only Health Care Qualit<a title="Patient Safety & Quality Healthcare page 47" href="http://viewer.zmags.com/publication/bc60bbb8?page=47">NEWS </a> NEWS <a title="Patient Safety & Quality Healthcare page 48" href="http://viewer.zmags.com/publication/bc60bbb8?page=48">Joint Healthcare Divisionand Society for Health</a> Joint Healthcare Divisionand Society for Health<a title="Patient Safety & Quality Healthcare page 49" href="http://viewer.zmags.com/publication/bc60bbb8?page=49">ASQ, HCD, HEALTH REFORM, AND YOU!The Summer of</a> ASQ, HCD, HEALTH REFORM, AND YOU!The Summer of<a title="Patient Safety & Quality Healthcare page 50" href="http://viewer.zmags.com/publication/bc60bbb8?page=50">Patient Safety and Quality Healthcare (PSQH)wel</a> Patient Safety and Quality Healthcare (PSQH)wel<a title="Patient Safety & Quality Healthcare page 51" href="http://viewer.zmags.com/publication/bc60bbb8?page=51"></a> <a title="Patient Safety & Quality Healthcare page 52" href="http://viewer.zmags.com/publication/bc60bbb8?page=52"></a>