PSQH<br />
Patient Safety & Quality Healthcare<br />
March/April 2012<br />
Volume 9, Issue 2<br />
We Have A NEW LOOK<br />
Read About Our Redesign on p.6<br />
Smart Pump Workarounds & Legal Risk<br />
Barcoding & Meaningful Use<br />
Evidence-Based Fall Prevention<br />
Q&A with Diane PinakiewiczASQBeutlich<br />
Hurricaine-OneContents<br />
March/April 2012 <br />
Volume 9, issue 2<br />
Features<br />
Smart Pump Workarounds: What’s the Legal Risk?<br />
By Tim Vanderveen, PharmD, MS<br />
Applying Lessons Learned to Accelerated Adoption of BCMA<br />
By Robert Bayly, MD, FCCM, FCCP; Susan Imhoff, RN, MSN<br />
Q & A with Diane Pinakiewicz<br />
‘Patient Safety Is Everyone’s Work’<br />
By Susan Carr<br />
Noah’s Story: Please Listen<br />
By Tanya Lord, MPH, PhD<br />
We Can All Define Patient Safety… or Can We? <br />
By Della M. Lin, MD; Sanjaya Kumar, MD<br />
DEPARTMENTS<br />
NEWS<br />
ABQAURP NEWS<br />
ADVERTISING INDEX<br />
CONFERENCE CAL<a title="Patient Safety & Quality Healthcare page 1" href="http://viewer.zmags.com/publication/f403b52f?page=1">PSQH Patient Safety & Quality Healthcare March/A</a>
<a title="Patient Safety & Quality Healthcare page 2" href="http://viewer.zmags.com/publication/f403b52f?page=2">ASQ</a>
<a title="Patient Safety & Quality Healthcare page 3" href="http://viewer.zmags.com/publication/f403b52f?page=3">Beutlich Hurricaine-One</a>
<a title="Patient Safety & Quality Healthcare page 4" href="http://viewer.zmags.com/publication/f403b52f?page=4">Contents March/April 2012 Volume 9, issue 2</a>
<a title="Patient Safety & Quality Healthcare page 5" href="http://viewer.zmags.com/publication/f403b52f?page=5">PDI</a>
<a title="Patient Safety & Quality Healthcare page 6" href="http://viewer.zmags.com/publication/f403b52f?page=6">LIONHEART PUBLISHING, INC. 506 Roswell St., Suite</a>
<a title="Patient Safety & Quality Healthcare page 7" href="http://viewer.zmags.com/publication/f403b52f?page=7">rLSolutions</a>
<a title="Patient Safety & Quality Healthcare page 8" href="http://viewer.zmags.com/publication/f403b52f?page=8">SPONORING ORGANIZATIONS ABQUARP ASPPS ASQ C</a>
<a title="Patient Safety & Quality Healthcare page 9" href="http://viewer.zmags.com/publication/f403b52f?page=9">unSUMMIT</a>
<a title="Patient Safety & Quality Healthcare page 10" href="http://viewer.zmags.com/publication/f403b52f?page=10">NEWS AHRQ Offers free Quality Indicators Tool</a>
<a title="Patient Safety & Quality Healthcare page 11" href="http://viewer.zmags.com/publication/f403b52f?page=11">NIST Releases Technical Guidance for Evaluating El</a>
<a title="Patient Safety & Quality Healthcare page 12" href="http://viewer.zmags.com/publication/f403b52f?page=12">AHRQ Evidence-Based Methods and Tools Help Redu</a>
<a title="Patient Safety & Quality Healthcare page 13" href="http://viewer.zmags.com/publication/f403b52f?page=13">program developed for nursing facilities by resear</a>
<a title="Patient Safety & Quality Healthcare page 14" href="http://viewer.zmags.com/publication/f403b52f?page=14">Health IT & Quality Sensory Overload? By Bar</a>
<a title="Patient Safety & Quality Healthcare page 15" href="http://viewer.zmags.com/publication/f403b52f?page=15">Health Tracking A San Francisco start-up develop</a>
<a title="Patient Safety & Quality Healthcare page 16" href="http://viewer.zmags.com/publication/f403b52f?page=16">Meaningful Use The Next Stage for BCMA By Jami</a>
<a title="Patient Safety & Quality Healthcare page 17" href="http://viewer.zmags.com/publication/f403b52f?page=17">SaferHealthcare</a>
<a title="Patient Safety & Quality Healthcare page 18" href="http://viewer.zmags.com/publication/f403b52f?page=18">Human Factors Design Principles for Manual Safe</a>
<a title="Patient Safety & Quality Healthcare page 19" href="http://viewer.zmags.com/publication/f403b52f?page=19">with minimal effort both by the direct user and by</a>
<a title="Patient Safety & Quality Healthcare page 20" href="http://viewer.zmags.com/publication/f403b52f?page=20">safety feature itself has introduced new hazards. </a>
<a title="Patient Safety & Quality Healthcare page 21" href="http://viewer.zmags.com/publication/f403b52f?page=21">National Patient Safety Foundation CBPPS</a>
<a title="Patient Safety & Quality Healthcare page 22" href="http://viewer.zmags.com/publication/f403b52f?page=22">Smart Pump Workarounds: What’s the Legal Risk? By</a>
<a title="Patient Safety & Quality Healthcare page 23" href="http://viewer.zmags.com/publication/f403b52f?page=23">In the past few years the need to improve intraven</a>
<a title="Patient Safety & Quality Healthcare page 24" href="http://viewer.zmags.com/publication/f403b52f?page=24">WHAT’S THE LEGAL RISK? about 54% of potential A</a>
<a title="Patient Safety & Quality Healthcare page 25" href="http://viewer.zmags.com/publication/f403b52f?page=25">therefore, not anticipating the storm’s potential </a>
<a title="Patient Safety & Quality Healthcare page 26" href="http://viewer.zmags.com/publication/f403b52f?page=26">WHAT’S THE LEGAL RISK? Table 2. Examples of “Go</a>
<a title="Patient Safety & Quality Healthcare page 27" href="http://viewer.zmags.com/publication/f403b52f?page=27">each hospital’s data, and a System Analytics Team </a>
<a title="Patient Safety & Quality Healthcare page 28" href="http://viewer.zmags.com/publication/f403b52f?page=28">Applying Lessons Learned to Accelerated Adoption o</a>
<a title="Patient Safety & Quality Healthcare page 29" href="http://viewer.zmags.com/publication/f403b52f?page=29">When JFK Medical Center in central New Jersey went</a>
<a title="Patient Safety & Quality Healthcare page 30" href="http://viewer.zmags.com/publication/f403b52f?page=30">Precision Dynamics Corp.</a>
<a title="Patient Safety & Quality Healthcare page 31" href="http://viewer.zmags.com/publication/f403b52f?page=31">Precision Dynamics Corp</a>
<a title="Patient Safety & Quality Healthcare page 32" href="http://viewer.zmags.com/publication/f403b52f?page=32">APPLYING LESSONS LEARNED who works with nurses </a>
<a title="Patient Safety & Quality Healthcare page 33" href="http://viewer.zmags.com/publication/f403b52f?page=33">Applying Lessons Learned Mary Pat Boehler, RP</a>
<a title="Patient Safety & Quality Healthcare page 34" href="http://viewer.zmags.com/publication/f403b52f?page=34">APPLYING LESSONS LEARNED Put it into context. </a>
<a title="Patient Safety & Quality Healthcare page 35" href="http://viewer.zmags.com/publication/f403b52f?page=35">hospital processes. The nurse rounders supporting </a>
<a title="Patient Safety & Quality Healthcare page 36" href="http://viewer.zmags.com/publication/f403b52f?page=36">Q & A with Diane Pinakiewicz ‘Patient Safety Is E</a>
<a title="Patient Safety & Quality Healthcare page 37" href="http://viewer.zmags.com/publication/f403b52f?page=37">to hospital programs that focus on singular patien</a>
<a title="Patient Safety & Quality Healthcare page 38" href="http://viewer.zmags.com/publication/f403b52f?page=38">Patient Safety iS everyone’s Work complete tran</a>
<a title="Patient Safety & Quality Healthcare page 39" href="http://viewer.zmags.com/publication/f403b52f?page=39">launched this program, we have had physicians, nur</a>
<a title="Patient Safety & Quality Healthcare page 40" href="http://viewer.zmags.com/publication/f403b52f?page=40">Noah’s Story: Please Listen By Tanya Lord, MPH, P</a>
<a title="Patient Safety & Quality Healthcare page 41" href="http://viewer.zmags.com/publication/f403b52f?page=41">Friday, June 4, 1999 Voorhees, New Jersey I tal</a>
<a title="Patient Safety & Quality Healthcare page 42" href="http://viewer.zmags.com/publication/f403b52f?page=42">Noah’s story and there didn’t seem to be anythi</a>
<a title="Patient Safety & Quality Healthcare page 43" href="http://viewer.zmags.com/publication/f403b52f?page=43">I have learned since then that the hospital’s disc</a>
<a title="Patient Safety & Quality Healthcare page 44" href="http://viewer.zmags.com/publication/f403b52f?page=44">Quality Colloquium</a>
<a title="Patient Safety & Quality Healthcare page 45" href="http://viewer.zmags.com/publication/f403b52f?page=45">Quality Colloquium</a>
<a title="Patient Safety & Quality Healthcare page 46" href="http://viewer.zmags.com/publication/f403b52f?page=46">Noah’s story of a grieving mother experiencing </a>
<a title="Patient Safety & Quality Healthcare page 47" href="http://viewer.zmags.com/publication/f403b52f?page=47">PSQH Point of Care Supplement For the July/Augu</a>
<a title="Patient Safety & Quality Healthcare page 48" href="http://viewer.zmags.com/publication/f403b52f?page=48">We Can All Define Patient Safety… or Can We? By D</a>
<a title="Patient Safety & Quality Healthcare page 49" href="http://viewer.zmags.com/publication/f403b52f?page=49">trary to published research that indicates a lack </a>
<a title="Patient Safety & Quality Healthcare page 50" href="http://viewer.zmags.com/publication/f403b52f?page=50">Defining Patient Safety counting, physicians who </a>
<a title="Patient Safety & Quality Healthcare page 51" href="http://viewer.zmags.com/publication/f403b52f?page=51">but their highest ranking words in this exercise w</a>
<a title="Patient Safety & Quality Healthcare page 52" href="http://viewer.zmags.com/publication/f403b52f?page=52">ISMP Building Patient Safety Skills: Common Pit</a>
<a title="Patient Safety & Quality Healthcare page 53" href="http://viewer.zmags.com/publication/f403b52f?page=53">volved individuals. Each at-risk behavior should a</a>
<a title="Patient Safety & Quality Healthcare page 54" href="http://viewer.zmags.com/publication/f403b52f?page=54">Table 2. Probing Questions to Identify Proximate c</a>
<a title="Patient Safety & Quality Healthcare page 55" href="http://viewer.zmags.com/publication/f403b52f?page=55">observe the environment and processes firsthand or</a>
<a title="Patient Safety & Quality Healthcare page 56" href="http://viewer.zmags.com/publication/f403b52f?page=56">ABQAURP NEWS American Board of Quality Assurance </a>
<a title="Patient Safety & Quality Healthcare page 57" href="http://viewer.zmags.com/publication/f403b52f?page=57">IS YOUR MEDICAL EDUCATION ACCREDITED? ABQAURP wel</a>
<a title="Patient Safety & Quality Healthcare page 58" href="http://viewer.zmags.com/publication/f403b52f?page=58">April 17–20 SHCA Annual Conference Society for H</a>
<a title="Patient Safety & Quality Healthcare page 59" href="http://viewer.zmags.com/publication/f403b52f?page=59">ABQUARP</a>
<a title="Patient Safety & Quality Healthcare page 60" href="http://viewer.zmags.com/publication/f403b52f?page=60">Standard Register</a>
<a title="Patient Safety & Quality Healthcare page 61" href="http://viewer.zmags.com/publication/f403b52f?page=61">Patient Safety & Quality Healthcare Education & T</a>
<a title="Patient Safety & Quality Healthcare page 62" href="http://viewer.zmags.com/publication/f403b52f?page=62">Introduction This sponsored supplement to Patie</a>
<a title="Patient Safety & Quality Healthcare page 63" href="http://viewer.zmags.com/publication/f403b52f?page=63">Northwestern University</a>
<a title="Patient Safety & Quality Healthcare page 64" href="http://viewer.zmags.com/publication/f403b52f?page=64">Society of Hospital Medicine Hospitalists play </a>
<a title="Patient Safety & Quality Healthcare page 65" href="http://viewer.zmags.com/publication/f403b52f?page=65">Society of Hospital Medicine</a>
<a title="Patient Safety & Quality Healthcare page 66" href="http://viewer.zmags.com/publication/f403b52f?page=66">Apollo Publishing, Inc. Just Culture Written by </a>
<a title="Patient Safety & Quality Healthcare page 67" href="http://viewer.zmags.com/publication/f403b52f?page=67">Five elements of a Safety Culture: Just Culture</a>
<a title="Patient Safety & Quality Healthcare page 68" href="http://viewer.zmags.com/publication/f403b52f?page=68">National Patient Safety Foundation</a>
<a title="Patient Safety & Quality Healthcare page 69" href="http://viewer.zmags.com/publication/f403b52f?page=69">National Patient Safety Foundation CBPPS</a>
<a title="Patient Safety & Quality Healthcare page 70" href="http://viewer.zmags.com/publication/f403b52f?page=70">ABQAURP- American Board of Quality Assurance & Uti</a>
<a title="Patient Safety & Quality Healthcare page 71" href="http://viewer.zmags.com/publication/f403b52f?page=71">Certification Board for Professionals in Patient S</a>
<a title="Patient Safety & Quality Healthcare page 72" href="http://viewer.zmags.com/publication/f403b52f?page=72">Medical Simulation Corporation (MSC) Address: 464</a>
<a title="Patient Safety & Quality Healthcare page 73" href="http://viewer.zmags.com/publication/f403b52f?page=73">University of Florida</a>
<a title="Patient Safety & Quality Healthcare page 74" href="http://viewer.zmags.com/publication/f403b52f?page=74">Outcome Engenuity Address: 1600 N Dallas Pkwy, St</a>
<a title="Patient Safety & Quality Healthcare page 75" href="http://viewer.zmags.com/publication/f403b52f?page=75"> Lean Supply Chain for Healthcare Degree or Certi</a>
<a title="Patient Safety & Quality Healthcare page 76" href="http://viewer.zmags.com/publication/f403b52f?page=76">University of Michigan</a>