Your Patient Safety Survival Guide

by Gretchen LeFever Watson

  ———. “Trail of Errors Led to 3 Wrong Brain Surgeries: Surgeons’ Ego at R.I. Hospital May Have Led to Carelessness, Study Says.” December 14, 2007. http://www.nbcnews.com/id/22263412/ns/health-health_care/t/trail-errors-led-wrong-brain-surgeries/#.VedHytNVhBc.

  Badjie, Ismaila D. “Presentation to Center for Medication Safety Advancement: Impact of Technology on Medication Safety.” Purdue University, 2012.

  Bates, D. W., L. L. Leape, D. J. Cullen, N. Laird, L. A. Petersen, J. M. Teich, E. Burdick et al. “Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors.” Journal of the American Medical Association 280 (1998): 1311–6.

  Bates, D. W., N. Spell, D. J. Cullen et al. “The Costs of Adverse Drug Events in Hospitalized Patients.” JAMA 277, no. 4 (1997): 307–11.

  Beccaro, Mark A. Del, Howard E. Jeffries, Matthew E. Eisenberg, and E. D. Harry. “Computerized Provider Order Entry Implementation: No Association with Increased Mortality Rates in an Intensive Care Unit.” Pediatrics 118, no. 1 (2006): 290–95.

  Berwick, Donald M. “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist.” Health Affairs 28 (2009): w55–w65.

  Binder, Leah. “The Leapfrog Annual Hospital Survey.” Personal communication (email), 2013.

  ———. “Stunning News on Preventable Deaths in Hospitals.” Forbes Magazine (2013). September 23, 2013. http://www.forbes.com/sites/leahbinder/2013/09/23/stunning-news-on-preventable-deaths-in-hospitals/.

  Binder, Leah, and William H. Finck. “Results of the 2013 Leapfrog Hospital Survey: Executive Summary.” July 9, 2015. http://www.leapfroggroup.org/sites/default/files/Files/2013LeapfrogHospitalSurveyResultsReport.pdf.

  Birkmeyer, J. D., and J. B. Dimick. “Leapfrog Safety Standards: Potential Benefits of Universal Adoption.” In Fact Sheet: Computerized Physician Order Entry. The Leapfrog Group, 2014.

  Bittle, M. J., and S. LaMarch. “Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care.” The Joint Commission Journal on Quality and Patient Safety 35, no. 10 (2009): 519–25.

  Blanco, Mary, John R. Clarke, and Denise Martindell. “Wrong Site Surgery Near Misses and Actual Occurrences.” AORN Journal 90, no. 2 (2009): 215–22.

  Borns, Patricia. “Investigation: Addicted Nurses Steal Patients’ Drugs: In Virginia, a Broken System of Employers and State Programs Allow It to Continue.” Investigation: Addicted Nurses (2016). http://www.newsleader.com/topic/997446b5-cea1-4493-b989-548be165cc47/addicted-nurses/.

  Brennan, T. A., L. L. Leape, N. Laird et al. “Incidence of Adverse Events and Negligence in Hospitalized Patients: Results from the Harvard Medical Practice Study.” New England Journal of Medicine 324 (1991): 370–76.

  Bria, William F. “The Electronic Health Record: Is It Meaningful Yet?” Mayo Clinic Proceedings 86, no. 5 (2011): 373–74.

  Brooks, R. L. “Are You Using the Universal Protocol Yet?” AAOS Now 9, no. 5 (2015). http://www.aaos.org/news/bulletin/marapr07/clinical6.asp.

  Brownlee, Shannon. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. New York: Bloomsbury, 2008.

  Burke, G. H., G. B. LeFever, and S. M. Sayles. “Zero Events of Harm to Patients: Building and Sustaining a System-Wide Culture of Safety at Sentara Healthcare.” Managing Infection Control (2009): 44–50. http://www.yoursls.com/Culture-Safety-Healthcare.pdf.

  Call, Josep, Juliane Brauer, Juliane Kaminski, and Michael Tomasello. “Domestic Dogs (Canis familiaris) Are Sensitive to the Attentional State of Humans.” Comparative Psychology 117, no. 3 (2003): 257–63.

  Campbell, E. G., S. Regan, R. L. Gruen, T. G. Ferris, S. R. Rao, P. D. Cleary, and D. Blumenthal. “Professionalism in Medicine: Results of a National Survey of Physicians.” Annals of Internal Medicine 147, no. 795 (2007): 208.

  Carr, D. F. “Electronic Health Records: First, Do No Harm?” InformationWeek. July 1, 2014. http://www.informationweek.com/healthcare/electronic-health-records/electronic-health-records-first-do-no-harm/a/d-id/1278834.

  Castlight Health. “Results of the 2014 Leapfrog Hospital Survey: Computerized Physician Order Entry.” 2015.

  CBS. “Hospital Agrees to Pay $8.25M in Baby’s Death from Overdose.” CBS Chicago. April 5, 2012. http://chicago.cbslocal.com/2012/04/05/babys-death-yields-record-settlement-of-more-than-8m/.

  Center for Advancing Health. “A New Definition of Patient Engagement: What Is Engagement and Why Is It Important?” Washington DC, 2010.

  Centers for Disease Control and Prevention. “General Information About MRSA in the Community.” Centers for Disease Control and Prevention.

  ———. “New Research Reveals the Trends and Risk Factors Behind America’s Growing Heroin Epidemic.” news release, July 7, 2015. http://www.cdc.gov/media/releases/2015/p0707-heroin-epidemic.html.

  ———. “Therapeutic Drug Use.” FastStats. May 14, 2015. http://www.cdc.gov/nchs/fastats/drug-use-therapeutic.htm.

  Charles, D., M. Gabriel, and M. F. Furukawa. “Adoption of Electronic Health Record Systems among U.S. Non-Federal Acute Care Hospitals: 2008–2013.” ONC. https://www.healthit.gov/sites/default/files/oncdatabrief16.pdf.

  Chassin, M. R., and J. M. Loeb. “High-Reliability Health Care: Getting There from Here.” Milbank Quarterly 91, no. 3 (2013): 459–90.

  Clancy, Carolyn M. “Alleviating ‘Secondary Victim’ Syndrome: How We Should Handle Patient Harm.” Journal of Nursing Care Quality 27, no. 1 (2012): 1–5.

  Clark, Noreen M., Linda Joe Doctor, Amy R. Friedman, Laurie L. Lachance, Christy R. Houle, Xin Geng, and Jeanne Ann Grisso. “Community Coalitions to Control Chronic Disease: Allies against Asthma as a Model and Case Study.” Health Promotion Practice 7, no. 2 (Supplement) (2006): 14S–22S.

  Clarke, John R. “Is Your Office Helping You Prevent Wrong Site Surgery?” Bulletin 99, no. 4 (2014). http://bulletin.facs.org/2014/04/is-your-office-helping-you-prevent-wrong-site-surgery/.

  ———. “The Use of Collaboration to Implement Evidence-Based Safe Practices.” Journal of Public Health Research 2, no. 150–53 (2013).

  Clarke, John R., Janet Johnston, and Edward D. Finley. “Getting Surgery Right.” Annals of Surgery 246, no. 3 (2007): 395–405.

  Classen, D. C., R. Resar, F. Griffin, F. Federico, T. Frankel, N. Kimmel, J. C. Whittington et al. “‘Global Trigger Tool’ Shows That Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured.” Health Affairs 30, no. 58 (2011): 1–9.

  Consumer Healthcare Products Association. “Statistics on OTC Use.” (2015). http://www.chpa.org/marketstats.aspx.

  Coulter, Angela, and Jo Ellins. “Effectiveness of Strategies for Informing, Educating, and Involving Patients.” BMJ: British Medical Journal 335, no. 7609: 24–27.

  Cummings, K. L., D. J. Anderson, and K. S. Kaye. “Hand Hygiene Noncompliance and the Cost of Hospital-Acquired Methicillin-Resistant Staphylococcus aureus Infection.” Infection Control and Hospital Epidemiology 31, no. 4 (2010): 357–64.

  Deis, J. N., K. M. Smith, M. D. Warren, P. G. Throop, G. B. Hickson, B. J. Joers, and J. K. Deshpande. “Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement.” In Advances in Patient Safety: New Directions and Alternative Approaches, edited by K. Henriksen, J. B. Battles, and M. A. Keyes. Rockville, MD: Agency for Healthcare Research and Quality, 2008.

  Delbanco, Tom, Donald M. Berwick, Jo Ivey Boufford, S. Edgman-Levitan, Günter Ollenschläger, Diane Plamping, and Richard G. Rockefeller. “Healthcare in a Land Called PeoplePower: Nothing About Me without Me.” Health Expectations 4, no. 3 (2001): 144–50.

  Denham Charles R., P. Angood, D. Berwick et al. “The Chasing Zero Department: Making Idealized Design a Reality.” Journal of Patient Safety 5, no. 210–215 (2009a).

  Denham, Charles R., Peter Angood, Don Berwick, Leah Binder, Carolyn M. Clancy, Janet M. Corrigan, and
David Hunt. “Chasing Zero: Can Reality Meet the Rhetoric?” Journal of Patient Safety 5, no. 4 (2009b): 216–22.

  ———. “The Vital Link Department: Making Idealized Design a Reality.” Journal of Patient Safety 5, no. 4 (2009): 216–22.

  Department of Education. “Human Performance Improvement Handbook.” Washington, DC: U.S. Depatment of Energy, 2009.

  deWit, Melanie E., Clifford M. Marks, Jeffrey P. Natterman, and Albert W. Wu. “Supporting Second Victims of Patient Safety Events: Shouldn’t These Communications Be Covered by Legal Privilege?” Journal of Law, Medicine, and Ethics (Winter 2013): 2–8.

  Doak, Cecelia Conrath, Leonard G. Doak, and Jane H. Root. “The Literacy Problem.” In Teaching Patients with Low Literacy Skills, 1–9. Philadelphia: J. B. Lippincott Co., 1996.

  Dowell, D., T. M. Haegerich, and R. Chou. “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016.” JAMA 315, no. 15 (2016): 1624–45.

  Doyle, Arthur Conan. The Complete Sherlock Holmes. New York: Bantam Classics, 1986.

  Duhigg, C. The Power of Habit: Why We Do What We Do in Life and Business. New York: Random House, 2014.

  Duncan, Christopher Paul, and Carol Dealey. “Patients’ Feelings About Hand Washing, MRSA Status and Patient Information.” British Journal of Nursing 16, no. 1 (2007): 34–38.

  Entwistle, Vikki. “Nursing Shortages and Patient Safety Problems in the Hospital Care: Is Clinical Monitoring by Families Part of the Solution?” Health Expectations 7 (2004): 1–5.

  Entwistle, Vikki, Michelle M. Mello, and Troyen A. Brennan. “Advising Patients About Patient Safety: Current Initiatives Risk Shifting Responsibility.” Journal on Quality and Patient Safety 31, no. 9 (2005): 483–94.

  Epstein, Randi Hutter. Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank. New York: W. W. Norton and Company, 2010.

  Etchegaray, Jason M., Madelene J. Ottosen, Landrus Burress, William M. Sage, Sigall K. Bell, Thomas H. Gallagher, and Eric J. Thomas. “Structuring Patient and Family Involvement in Medical Error Event Disclosure and Analysis.” Health Affairs 33, no. 1 (2014): 46–52.

  Fawcett, S. B., A. Paine-Andrews, V. T. Francisco, J. A. Schultz, K. P. Richter, R. K. Lewis, E. L. Williams et al. “Using Empowerment Theory in Collaborative Partnership for Community Health and Development.” American Journal of Community Psychology 23, no. 5 (1995): 677–97.

  Fein, Stephanie P., Lee H. Hilborne, Eugene M. Spiritus, Gregory B. Seymann, Craig R. Keenan, Kaveh G. Shojania, Marjorie Kagawa-Singer, and Neil S. Wenger. “The Many Faces of Error Disclosure: A Common Set of Elements and a Definition.” Journal of General Internal Medicine 22, no. 6 (2007): 755–61.

  Foster-Fishman, P. G., S. L. Berkowitz, D. W. Lounsbury, S. Jacobson, and N. A. Allen. “Building Collaborative Capacity in Community Coalitions: A Review and Integrative Framework.” American Journal of Community Psychology 29, no. 2241–261 (2001).

  Frith, K., E. Anderson, F. Tseng, and E. Fong. “Nurse Staffing Is an Important Strategy to Prevent Medication Errors in Community Hospitals.” Nursing Economics 30, no. 5 (2012): 288–94.

  Gallagher, T. H., A. D. Waterman, J. M. Garbutt et al. “US and Canadian Physicians’ Attitudes and Experiences Regarding Disclosing Errors to Patients.” Archives of Internal Medicine 166, no. 15 (2006): 1605–11.

  Gandhi, Tejal K., and Gregg S. Meyer. “United for Patient Safety: National Patient Safety Foundation Report 2014–2015.” Boston, MA: National Patient Safety Foundation, 2016.

  Garbutt, Jane, D. R. Brownstein, E. J. Klein, Amy D. Waterman, M. J. Krauss, E. K. Marcuse, Erik Hazel et al. “Reporting and Disclosing Medical Errors: Pediatricians’ Attitudes and Behaviors.” Archives of Pediatric and Adolescent Medicine 16, no. 2 (2007): 179–85.

  Gardner, A. “Surgery Mix-Ups Surprisingly Common.” October 18, 2010. http://www.cnn.com/2010/HEALTH/10/18/health.surgery.mixups.common/.

  Gawande, A. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books, 2009.

  Gibson, Rosemary, and Janardan Prasad Singh. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. Washington, DC: LifeLine Press, 2003.

  Gladwell, Malcolm. Outliers: The Story of Success. New York: Little, Brown and Company, 2008.

  Gorovitz, Samuel, and Alasdair MacIntyre. “Toward a Theory of Medical Fallibility.” Hastings Center Report (December 1975): 13–23.

  Grissinger, Matthew. “The Five Rights: A Destination without a Map.” Pharmacy and Therapeutics 35, no. 10 (2010): 542.

  Grol, R., D. M. Berwick, and M. Wensing. “On the Trail of Quality and Safety in Health Care.” BMJ: British Medical Journal 336, no. 7635 (2008): 74–76.

  Halbesleben, Jonathon, R. B. Grant Savage, Douglas S. Wakefield, and Bonnie J. Wakefield. “Rework and Workarounds in Nurse Medication Administration Process: Implications for Work Processes and Patient Safety.” Health Care Management Review 35, no. 2 (2010): 124–33.

  Hamilton, Norman. “Suicide of Nurse after Tragic Event.” Seattle Times, April 22, 2011.

  Hardin, Garrett. “The Tragedy of the Commons.” Science 162, no. 13 (1968): 1243–48.

  Heath, Chip, and Dan Heath. Made to Stick: Why Some Ideas Survive and Others Die. New York: Random House, 2007.

  Hendrich, Ann, Christine Kocot McCoy, Jane Gale, Lora Sparkman, and Palmira Santos. “Ascension Health’s Demonstration of Full Disclosure Protocol for Unexpected Events During Labor and Delivery Shows Promise.” Health Affairs 33, no. 1 (2014): 39–45.

  Herring, Mark. “An Epidemic of Opioid Death.” The Virginian-Pilot, September 21, 2016.

  Hibbard, Judith H., Ellen Peters, Paul Slovic, and Martin Tusler. “Can Patients Be Part of the Solution? Views on Their Role in Preventing Medical Errors.” Medical Care Research and Review 62, no. 5 (October 1, 2005): 601–16.

  Hibbard, J. H., J. Stockard, and M. Tusler. “Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?” Health Affairs 22, no. 2 (2003): 84–94.

  Hickson, G. B., E. W. Clayton, P. B. Githens, and F. A. Sloan. “Factors That Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries.” Journal of the American Medical Association 267 (1992): 1359–63.

  Iglehart, John K. “Improved Safety, Eliminating Errors Top Policy Agenda.” Health Affairs 33, no. 1 (2014): 6.

  Infection Control Today. “Hospitals Pair Germ-Killing Robots with CDC Protocols to Protect against Ebola Virus.” Infection Control Today, October 30, 2014. http://www.infectioncontroltoday.com/news/2014/10/hospitals-pair-germkilling-robots-with-cdc-protocols-to-protect-against-ebola-virus.aspx.

  Institute for Safe Medication Practices. “The Five Rights: A Destination Without a Map.” https://www.ismp.org/newsletters/acutecare/articles/20070125.asp.

  ———. “Independent Double-Checks: Undervalued and Misused.” https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=51.

  ———. “Since When Is It a Crime to Be Human?” news release, 2006. http://www.ismp.org/pressroom/viewpoints/julie.asp.

  Institute of Medicine. “Patient Safety: Achieving a New Standard of Care.” Washington, DC: National Academies Press, 2004.

  ———. “Preventing Medication Errors.” Washington, DC: National Academy Press, 2006.

  Ioannidis, John P. A. “Why Most Published Research Findings Are False.” PLoS Medicine 2, no. 8 (2007): 696–701.

  Jacquet, Jennifer. Is Shame Necessary? New Uses for an Old Tool. New York: Random House, 2015.

  James, J. T. “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9, no. 3 (2013): 122–28.

  Jauhar, Sandeep. Doctored: The Disillusionment of an American Physician. New York: Farrar, Straus, and Giroux, 2014.

  Jena, Anupam B., Seth Seabury, Darius Lakdawalla, and Amitabh Chandra
. “Malpractice Risk According to Physician Specialty.” New England Journal of Medicine 365, no. 629–36 (2011).

  Jewell, K., and L. McGiffert. “To Err Is Human—to Delay Is Deadly: Ten Years Later, a Million Lives Lost, Billions of Dollars Wasted.” Consumers Union: Nonprofit Publishers of Consumer Reports, May 2009. http://safepatientproject.org/pdf/safepatientproject.org-to_delay_is_deadly-2009_05.pdf.

  Joint Commission on Accreditation of Healthcare Organizations. “Speak Up: Help Prevent Errors in Your Care.” In JCAHCO, edited by Joint Commission on Accreditation of Health Care Organizations, 2003.

  Kachalia, Allen, Samuel R. Kaufman, Richard Boothman, Susan Anderson, Kathleen Welch, Sanjay Saint, and Mary A. M. Rogers. “Liability Claims and Costs before and after Implementation of a Medical Error Disclosure Program.” Annals of Internal Medicine 153, no. 4 (2010): 213–22.

  Kachalia, Allen, Alison Little, Melissa Isavoran, Lynn-Marie Crider, and Jeanene Smith. “Greatest Impact of Safe Harbor Rule May Be to Improve Patient Safety, Not Reduce Liability Claims Paid by Physicians.” Health Affairs 33, no. 1 (2014): 59–66.

  Kane, C. “Policy Research Perspectives—Medical Liability Claim Frequency: A 2007–2008 Snapshot of Physicians.” Chicago: American Medical Association, 2010, 1–7.

  Kane, J. M., M. Brannen, and E. Kern. “Impact of Patient Safety Mandates on Medical Education in the United States.” Journal of Patient Safety 4, no. 2 (June 2008): 93–97.

  Kavanagh, Margaret. “Virginia Beach School Board Member Shares Painful Memories of Daughter’s Overdose.” The Virginian-Pilot, July 8, 2015.

  Kesselheim, Aaron S., Kathrin Cresswell, Shobha Phansalkar, David W. Bates, and Aziz Sheikh. “Clinical Decision Support Systems Could Be Modified to Reduced ‘Alert Fatigue’ While Still Minimizing the Risk of Litigation.” Health Affairs 30, no. 12 (2011): 2310–17.

  King, Sorrel. Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safer. New York: Atlantic Monthly Press, 2009.