Your Patient Safety Survival Guide

by Gretchen LeFever Watson

Kirle, Leslie. “Errors in Transcribing and Administering Medications.” Safety First Alert, January 2001. http://www.macoalition.org/documents/SafetyFirst3.pdf.

  Kirsch, Irwin S., Ann Jungeblut, Lynn Jenkins, and Andrew Kolstad. “Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey.” Office of Educational Research and Improvement: U.S. Department of Education, 2002.

  Klevens, R. M., J. R. Edwards, C. L. Richards, T. C. Horan, R. P. Gaynes, D. A. Pollock, and D. M. Cardo. “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002.” Public Health Reports 122 (2007): 160–66.

  Kliff, Sarah. “Medical Errors in America Kill More People Than Aids or Drug Overdoses. Here’s Why.” Vox, April 22, 2015. http://www.vox.com/2015/1/29/7878731/medical-errors-statistics.

  Kohn, L. T., J. M. Corrigan, and M. S. Donaldson. “To Err Is Human: Building a Safer Health System.” Washington, DC: Institute of Medicine, 1999.

  ———. To Err Is Human: Building a Safer Health System. Edited by Institute of Medicine Committee on Quality Health Care in America. Washington, DC: National Academies Press, 2000.

  Kopp, Carol. “Anatomy of a Mistake.” CBS News, March 16, 2003. http://www.cbsnews.com/news/anatomy-of-a-mistake-16-03-2003/.

  Koppel, R., T. Wetterneck, J. Telles, and B. Karsh. “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety.” Journal of the American Medical Informatics Association 15, no. 4 (2008): 408–23.

  Kovner, Christine T., Carol S. Brewer, Farida Fatehi, and Jin Jun. “What Does Nurse Turnover Rate Mean and What Is the Rate?” Policy, Politics, & Nursing Practice 15, no. 3–4 (2014): 64–71.

  Kraft-Todd, Gordon, E. Yoeli, S. Bhanot, and D. Rand. “Promoting Cooperation in the Field.” Current Opinion in Behavioral Sciences 3, no. 0 (6// 2015): 96–101.

  Kraman, Steve S., and Ginny Hamm. “Risk Management: Extreme Honesty May Be the Best Policy.” Annals of Internal Medicine 131, no. 12 (1999): 963–67.

  Kumar, Sanjaya. Fatal Care: Survive in the U.S. Health System. Minneapolis, MN: IGI Press, 2008.

  Latane, Bibb, and Judith Rodin. “A Lady in Distress: Inhibiting Effects of Friends and Strangers on Bystander Intervention.” Journal of Experimental Social Psychology 5 (1969): 189–202.

  Lazarou, J., B. H. Pomeranz, and P. N. Corey. “Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-Analysis of Prospective Studies.” JAMA 279, no. 15 (1998): 1200–05.

  Leape, L. L. “Scope of Problem and History of Patient Safety.” Obstetric and Gynecological Clinics of North America 35 (2008): 1–10.

  Leape, L. L., D. W. Bates, D. J. Cullen et al. “Systems Analysis of Adverse Drug Events.” JAMA 274, no. 1 (1995): 35–43.

  Leape, L. L., and D. M. Berwick. “Five Years after To Err Is Human: What Have We Learned?” JAMA 293, no. 19 (2005): 2384–90.

  Leape, L. L., A. G. Lawthers, T. A. Brennan, and W. G. Johnson. “Preventing Medical Injury.” Quarterly Review Bulletein 19, no. 5 (1993): 144–49.

  Leape, L. L., M. F. Shore, J. L. Dienstag et al. “Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians.” Academic Medicine 87, no. 7 (2012): 845–52.

  The Leapfrog Group. “Factsheet: Bar Code Medication Administration.” http://www.leapfroggroup.org/sites/default/files/Files/BCMA_FactSheet.pdf.

  ———. “Fact Sheet: Computerized Physician Order Entry.” http://www.leapfroggroup.org/sites/default/files/Files/CPOE%20Fact%20Sheet.pdf.

  LeFever, G. B. “Chasing Zero Events of Harm: An Urgent Call to Expand Safety Culture Work and Patient Engagement.” Nursing and Patient Care (February 2010). http://www.yoursls.com/ConnectingHospitals-Communities.pdf.

  ———. “Issue Brief: Increased Use of Psychiatric Drugs in American Schools.” Arlington, VA: The Lexington Institute, 2002.

  LeFever, G. B., K. Allen, and E. A. Plasden. “Piloting a School-Wide Behavioral Intervention Study.” In 132nd Annual Meeting of the American Public Health Association. Washington, DC, 2004.

  LeFever, G. B., A. P. Arcona, and D. O. Antonuccio. “ADHD among American Schoolchildren: Evidence of Overdiagnosis and Overuse of Medication.” Scientific Review of Mental Health Practice 2, no. 1 (2003): 49–60.

  LeFever, G. B., F. D. Butterfoss, and N. Vislocky. “High Prevalence of Attention Deficit Hyperactivity Disorder: Catalyst for Development of a School Health Coalition.” Family and Community Health 22, no. 1 (1999): 38–49.

  LeFever, G. B., K. V. Dawson, and A. L. Morrow. “The Extent of Drug Therapy for Attention-Deficit/Hyperactivity Disorder among Children in Public Schools.” American Journal of Public Health 89, no. 9 (1999): 1359–64.

  LeFever, G. B., J. L. Parker, A. L. Morrow, and M. S. Villers. “Understanding ADHD Issues in a Community with a High ADHD Prevalence Rate: Parent, Teacher, and Provider Perspectives.” In 128th Annual Meeting of the American Public Health Association. Boston, MA, 2000.

  LeFever, G. B., M. S. Villers, A. L. Morrow, and E. S. Vaughn. “Parental Perceptions of Adverse Educational Outcomes among Children Diagnosed with ADHD: A Call for Improved School/Provider Collaboration.” Psychology in the Schools 39, no. 1 (2002): 63–71.

  Leonard, M., S. Graham, and D. Bonacum. “The Human Factor: The Critical Importance of Effective Teamwork and Communication in Providing Safe Care.” Quality and Safety in Health Care 13, no. Suppl 1 (2004): 85–90.

  Levinson, Daniel R. “Adverse Events in Skilled Nursing Facilities: National Incidence among Medicare Beneficiaries.” Washington, DC: Department of Health and Human Services, 2014.

  Liang, Stephen Y., Daniel L. Theodoro, Jeremiah D. Schuur, and Jonas Marschall. “Infection Prevention in the Emergency Department.” Infectious Disease 64, no. 3 (2014): 299–313.

  Liao, Joshua M., Eric J. Thomas, and Sigall K. Bell. “Speaking up About the Dangers of the Hidden Curriculum.” Health Affairs 33, no. 1 (2014): 168–71.

  Lucien Leape Institute. “Unmet Needs: Teaching Physicians to Provide Safe Patient Care.” Boston, MA: National Patient Safety Foundation, 2010.

  Lyons-Weiler, James. Chapter 6: Overdiagnosis of ADHD. In Cures vs. Profits: Successes in Translational Research. London: World Scientific, 2016.

  Mack, K. M., C. S. Kelly, and A. L. Morrow. “Head Start: A Setting for Asthma Outreach and Prevention.” Family and Community Health 22, no. 1 (1999): 28–37.

  Mackay, Alan L. A Dictionary of Scientific Quotations. London: CRC Press, 1991, 219.

  Makani, Hemadri. “Mark the Site Campaign.” In Success in Healthcare, 2012.

  Makary, Martin A., and Michael Daniel. “Medical Error—the Third Leading Cause of Death in the US.” BMJ 353.

  Makary, Martin A., Arnab Mukherjee, J. Bryan Sexton, Dora Syin, Emmanuelle Goodrich, Emily Hartmann, Lisa C. Rowen et al. “Operating Room Briefings and Wrong-Site Surgery.” Journal of the American College of Surgery 204, no. 236–243 (2007).

  Margolin, Frances S. “Getting to Zero: Reducing Rates of Clabsi in Community Hospitals.” (2011). http://www.leapfroggroup.org/media/file/Final_GettingToZero.pdf.

  Martinez, J. “What a Mess, Baby.” Daily News, March 22, 2007.

  Maurer, Maureen, Pam Dardess, Kristin L. Carman, Karen Frazier, and Lauren Smeeding. “Guide to Parent and Family Engagement: Environmental Scan Report.” In AHRQ Publication No. 12-0042-EF. Rockville, MD: Agency for Healthcare Research and Quality, 2012.

  McArdle, Megan. The Up Side of Down: Why Failing Well Is the Key to Success. New York: Penquin Books, 2015.

  McCloskey, D. J., M. A. McDonald, J. Cook, S. Heurtin-Roberts, S. Updegrove, D. Smapson, S. Gutter, and M. Eder. “Community Engagement: Definitions and Organizing Concepts from the Literature.” Edited by Public Health Practice Program Office. Atlanta, GA: Centers for Disease Control and Prevention, 2015.

  McGlynn, E
lizabeth A., Steven M. Asch, John Adams, Joan Keesey, Jennifer Hicks, Alison DeCristofaro, and Eve A. Kerr. “The Quality of Health Care Delivered to Adults in the United States.” New England Journal of Medicine 348, no. 26 (2003): 2635–45.

  McGuckin, M., R. Waterman, J. Storr, I. C. J. W. Bowler, M. Ashby, K. Topley, and L. Porten. “Evaluation of a Patient-Empowering Hand Hygiene Programme in the UK.” Journal of Hospital Infection 48, no. 3 (2001): 222–27.

  McNamara, S. A. “Incivility in Nursing: Unsafe Nurse, Unsafe Patients.” AORN Journal 95, no. 4 (2012): 535–40.

  Medical News Today. “Record 4.02 Billion Prescriptions in the United States in 2011.” MNT, September 14, 2012. http://www.medicalnewstoday.com/releases/250213.php.

  Mello, Michelle M., Richard C. Boothman, Timothy McDonald, Jeffrey Driver, Alan Lembitz, Darren Bouwmeester, Benjamin Dunlap, and Thomas Gallagher. “Communication-and-Resolution Programs: The Challenges and Lessons Learned from Six Early Adopters.” Health Affairs 33, no. 1 (2014): 20–29.

  Mello, Michelle M., Susan K. Senecal, Yelena Kuznetsov, and Janet S. Cohn. “Implementing Hospital-Based Communication-and-Resolution Programs: Lessons Learned in New York City.” Health Affairs 33, no. 1 (2014): 30–36.

  Mendelson, Dan, Rajeev Ramchand, Richard Abramson, and Anne Tumlinson. “Prescription Drugs in Nursing Homes: Managing Costs and Quality in a Complex Environment.” In NHPF Issue Brief. National Health Policy Forum, 2002.

  Mercer, Larry, Philip Felt, and Noell R. Snider. “Getting the Most out of Your Epic EMR Training Program.” White Paper (2012). http://divurgent.com/wp-content/uploads/pdf/EpicEMRTrainingProgram.pdf.

  Michaels, Robert K., Martin A. Makary, Yasser Dahab, Frank J. Frassica, Eugenie Heitmiller, Lisa C. Rowen, Richard Crotreau, Henry Brem, and Peter J. Pronovost. “Achieving the National Quality Forum’s ‘Never Events’: Prevention of Wrong Site, Wrong Procedure, and Wrong Patient Operations.” Annals of Surgery 245, no. 4 (2007): 526–32.

  Monash Institute of Health Service Research. “Literature Review Regarding Patient Engagement in Patient Safety Initiatives.” (2008). http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Literature-Review-Regarding-Patient-Engagement-in-Patient-Safety-Initiatives.pdf.

  Moore, T. J., M. R. Cohen, and C. D. Furberg. “Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998–2005.” Archives of Internal Medicine 167, no. 16 (2007): 1752–59.

  Morales, Tatiana. “Switched before Birth.” (2004). August 4, 2004. http://www.cbsnews.com/news/switched-before-birth/.

  National Patient Safety Agency. “Health Literacy: Statistics at-a-Glance.” April 2011. https://c.ymcdn.com/sites/www.npsf.org/resource/collection/9220B314-9666-40DA-89DA-9F46357530F1/AskMe3_Stats_English.pdf.

  ———. “National Agenda for Action: Patients and Families in Patient Safety—Nothing About Me, without Me.” https://c.ymcdn.com/sites/www.npsf.org/resource/collection/ABAB3CA8-4E0A-41C5-A480-6DE8B793536C/Nothing_About_Me.pdf.

  ———. “Safety Is Personal: Partnering with Patients and Families for the Safest Care.” Boston, MA: National Patient Safety Foundation, 2014.

  ———. “Wristbands for Hospital Inpatients Improves Safety.” http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60032.

  National Patient Safety Foundation. http://www.npsf.org/?page=aboutus.

  National Public Radio. “Atul Gawande’s ‘Checklist’ for Surgery Success.” Morning Edition, January 5, 2010. http://www.npr.org/templates/story/story.php?storyId=122226184.

  Novack, D. H., R. Plumer, R. L. Smith, H. Ochitill, G. R. Morrow, and J. M. Bennett. “Changes in Physicians’ Attitudes toward Telling the Cancer Patient.” JAMA 241, no. 9 (1979): 897–900.

  Occupational Safety and Health Administration. “Worker Safety in Your Hospital.” OSHA. https://www.osha.gov/dsg/hospitals/documents/1.1_Data_highlights_508.pdf.

  Okuyama, Ayako, Cordula Wagner, and Bart Bijnen. “Speaking up for Patient Safety by Hospital-Based Health Care Professionals: A Literature Review.” BMC Health Services Research 14 (2014): 61.

  Parker, Stacy. “Health Care Hero Awards: Corporate Achievements in Health Care.” Inside Business, February 17, 2012.

  Pascale, Richard, Jerry Sternin, and Monique Sternin. The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems. Boston, MA: Harvard Business Press, 2010.

  Pines, Jesse M., John J. Kelly, Helmut Meisl, James J. Augustine, Robert I. Broida, John R. Clarker, Heather Farley et al. “Procedural Safety in Emergency Care: A Conceptual Model and Recommendations.” Joint Commission Journal on Quality and Patient Safety 38, no. 11 (2012): 516–26.

  PR Newswire. “Boston Medical Center Teams up with Rhode Island Hospital, CVS Health to Address Use of Pharmacy-Based Naloxone to Combat Opioid Addiction and Overdoses.” news release, 2015. http://www.prnewswire.com/news-releases/boston-medical-center-teams-up-with-rhode-island-hospital-cvs-health-to-address-use-of-pharmacy-based-naloxone-to-combat-opioid-addiction-and-overdoses-300124914.html.

  Pratt, Sephen, Linda Kenney, Susan D. Scott, and Albert W. Wu. “How to Develop a Second Victim Support Program: A Toolkit for Health Care Organizations.” Joint Commission Journal on Quality and Patient Safety 38, no. 5 (2012): 235–40.

  Pronovost, Peter J., Christine A. Goeschel, Elizabeth Colantuoni, Sam Watson, Lisa H. Lubomski, Sean M. Berenholtz, David A. Thompson et al. “Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study.” BMJ: British Medical Journal 340 (2010): c309.

  Pronovost, Peter, Dale Needham, Sean Berenholtz, David Sinopoli, Haitao Chu, Sara Cosgrove, Bryan Sexton et al. “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU.” New England Journal of Medicine 355, no. 26 (2006): 2725–32.

  Pronovost, P. J., and E. Vohr. Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. New York: Penquin Group, 2010.

  Quinones, Sam. Dreamland: The True Tale of America’s Opiate Epidemic. Dexter, MI: Bloomsbury Press, 2015.

  Radley, David C., Melanie R. Wasserman, Lauren E. W. Olsho, Sarah J. Shoemaker, Mark D. Spranca, and Bethany Bradshaw. “Reduction in Medication Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems.” Journal of the American Medical Informatics Association 20, no. 3 (2013): 470–76.

  Reason, James. “Human Error: Models and Management.” BMJ: British Medical Journal 320, no. 7237 (2000): 768–70.

  Reinertsen, James L., Michael D. Bisgnano, and Maureen Pugh. Seven Leadership Leverage Points for Organizational-Level Improvement in Health Care. Cambridge, MA: Institute for Healthcare Improvement, 2008.

  Reising, Deanna L., and Patricia N. Allen. “Protecting Yourself from Malpractice Claims.” American Nurse Today (February 2007): 39–44.

  Revere, Audrey. “JCAHO National Patient Safety Goals for 2007.” Topics in Patient Safety 7, no. 1 (2007).

  Ring, David C., James H. Herndon, and Gregg S. Meyer. “Case 34-2010.” New England Journal of Medicine 363, no. 20 (2010): 1950–57.

  Robbins, Alexandra. The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. New York: Workman Publishing Company, Inc., 2015.

  Rosenstein, A. H., and M. O’Daniel. “A Survey of the Impact of Disruptive Behaviors and Communication Defects on Patient Safety.” Joint Commission Journal on Quality and Patient Safety 34, no. 8 (2008): 464–71.

  Rosenstock, I. M., V. J. Stretcher, and M. H. Becker. “Social Learning Theory and the Health Belief Model.” Health Education Quarterly 15, no. 2 (1988): 175–83.

  Rubin, G. Better Than Before: Mastering the Habits of Our Everyday Lives. New York: Crown Publishers, 2015.

  Saad, Karim. “Discovery & Action Dialogues: A Tool for Getting Started.” In SharedCare: Partners for Patients, edited by BC Patient Safet
y & Quality Council, 2013.

  Sack, K. “A Hospital Hand-Washing Project to Save Lives and Money.” New York Times, September 10 2009.

  Sandars, John, and Gary Cook. ABC of Patient Safety. Malden, MA: Blackwell Publishing, 2007.

  Schwarz, A. “Drowned in a Stream of Prescriptions.” New York Times, February 2 2013.

  ———. “The Selling of Attention Deficit Disorder.” New York Times, December 14 2013.

  Scott, R. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Centers for Disease Control and Prevention, 2009.

  Scott, Susan D. “The ‘Second Victim’ Phenomenon: A Harsh Reality of Health Care Professions.” Perpectives on Safety (May 2011). https://psnet.ahrq.gov/perspectives/perspective/102.

  Shannon, Sarah E., Mary Beth Foglia, Mary Hardy, and Thomas H. Gallagher. “Disclosing Errors to Patients: Perspectives of Registered Nurses.” The Joint Commission Journal on Quality and Patient Safety 35, no. 1 (2009): 5–12.

  Shekelle, P. G., R. M. Wachter, P. J. Pronovost, K. Schoelles, K. M. McDonald, S. M. Dy, K. Shojania, et al. “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices.” In Comparative Effectiveness Review No. 211, edited by Southern California-RAND Evidence-based Practice Cneter. Rockville, MD: Agency for Healthcare Research and Quality, 2013.

  Sickbert-Bennett, E. E., L. M. Dibiase, W. Schade, E. S. Wolak, D. J. Weber, and W. A. Rutala. “Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices.” Emerging Infectious Diseases 22, no. 9 (2016): 1628–30.

  Sidorov, J. “It Ain’t Necessarily So: The Electronic Health Record and the Unlikely Prospect of Reducing Health Care Costs: Much of the Literature on EHRS Fails to Support the Primary Rationales for Using Them.” Health Affairs 25, no. 4 (2006): 1079–85.

  Simpson, Elizabeth. “Va. Beach Psychiatrist’s License to Be Suspended.” Virginian-Pilot, October 28, 2014.

  Singhal, Arvind, and Karen Greiner. “Do What You Can with What You Have, Where You Are Now: A Quest to Eliminate MRSA at the Va Pittsburgh Healthcare System.” Deeper Learning 1, no. 4 (2007): 1–12.