Baldwin DM, Quintela J, Duclos C, Staton EW, Pace
WD. Patient preferences for notification of normal laboratory test results: a
report from the ASIPS Collaborative. BMC Fam Pract. 2005 Mar 8;6(1):11.
Donna.M.Baldwin@kp.org Full PDF version:
http://www.biomedcentral.com/1471-2296/6/11
Fernald DH, Pace WD, Harris
DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient
safety reporting system: a report from the ASIPS collaborative. Ann Fam Med.
2004 Jul-Aug;2(4):327-32.
Doug.fernald@uchsc.edu
Full PDF version:
http://www.annfammed.org/cgi/content/full/2/4/32
Pace WD, Staton EW, Higgins
GS, Main DS, West DR, Harris DM; ASIPS. Collaborative.
Database design to ensure anonymous study of medical errors: a report from the
ASIPS Collaborative. J Am Med Inform Assoc. 2003 Nov-Dec;10(6):531-40. Epub
2003 Aug 4.
wilson.pace@uchsc.edu
Full PDF version
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12925548
Smith PC, Araya-Guerra R,
Bublitz C, Parnes B, Dickinson LM, Van Vorst R, Westfall JM, Pace WD. Missing
clinical information during primary care visits. JAMA. 2005 Feb
2;293(5):565-71. Peter.smith@uchsc.edu
Westfall JM, Fernald DH,
Staton EW, VanVorst R, West D, Pace WD. Applied strategies for improving
patient safety: a comprehensive process to improve care in rural and frontier
communities. J Rural Health. 2004 Fall;20(4):355-62.
Jack.westfall@uchsc.edu
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Other Colorado
Patient Safety Publications |
Borgstede JP, Zinninger MD. Radiology
and patient safety. Acad Radiol. 2004 Mar;11(3):322-32. Penrose St. Francis
Health System, Colorado Springs, CO, USA.
Coleman EA, Mahoney E, Parry C.
Assessing the quality of preparation for posthospital care from the patient's
perspective: the care transitions measure.
Med Care. 2005 Mar;43(3):246-55. Division of
Health Care Policy and Research, University of Colorado Health Sciences Center,
Denver, Colorado 80011, USA. Eric.Coleman@uchsc.edu
Leonard M, Graham S, Bonacum D. The
human factor: the critical importance of effective teamwork and communication in
providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90.
Colorado Permanente Medical Group, Denver, U.S.A.
Mmleonard@att.net
Stratton KM, Blegen MA, Pepper G,
Vaughn T. Reporting of medication errors by pediatric nurses. J Pediatr Nurs.
2004 Dec;19(6):385-92. School of Nursing, University of Colorado Health Sciences
Center, Denver, CO, USA.
Smith JD, Coleman EA, Min SJ.
A new tool for identifying discrepancies in postacute medications for
community-dwelling older adults.
Am J Geriatr Pharmacother. 2004 Jun;2(2):141-7. Division of Health Care Policy
and Research, University of Colorado Health Sciences Center, Denver, CO, USA.
Jodi.D.Smith@kp.org
Woods D, Thomas E, Holl J, Altman S,
Brennan T. Adverse events and preventable adverse events in children.
Pediatrics. 2005 Jan;115(1):155-60. This publication looks at 3719 discharged
hospital patients (0-20 years old) and 7528 nonelderly (21-65 years old)
discharged adult patients in Colorado and Utah.
"To Err Is Human: Building a Safer Health System"
(Institute of Medicine of the National Academies;
1999). The Committee on the Quality of Health Care in America’s first report
identifying strategies for achieving a substantial improvement in the quality of
health care delivered to Americans. This landmark publication focusing on the
specific quality concern patient safety is available in its entirety on-line or
you can download a PDF summary version
Full HTML version
http://www.nap.edu/books/0309068371/html
Summary PDF Version
"Crossing the Quality Chasm: A New Health System for the 21st
Century" (Institute of Medicine of the National Academies; 2002).
The Committee on the Quality of Health Care in America’s second and final
report identifying strategies for achieving a substantial improvement in the
quality of health care delivered to Americans. This report concerns itself with
how the health care delivery system can be designed to innovate and improve
care. A summary PDF version can be downloaded or one can access the entire
report on-line.
Full HTML version
http://www.nap.edu/books/0309072808/html/
Summary PDF Version
“Training of Hospital
Staff To Respond to a Mass Casualty Incident.” Summary, Evidence
Report/Technology Assessment. Hsu EB, Jenckes MW, Catlett CL, et
al. Summary, Evidence Report/Technology Assessment: Number 95. AHRQ Publication
Number 04-E015-1, April 2004. Agency for Healthcare Research and Quality,
Rockville, MD.
Full HTML version
http://www.ahrq.gov/clinic/epcsums/hospmcisum.htm
Full
PDf Version
"A
Tale of Two Stories: Contrasting Views of Patient Safety--Report from a Workshop
on Assembling a Scientific Basis for Progress on Patient Safety"
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation;
1998. A report resulting from a workshop that
introduces accident investigation techniques using a collection of case studies.
This report also functions as a resource for further references concerning
investigation techniques.
Full PDF Version
“An Organisation
with a Memory: Report of an Expert Group on Learning from Adverse Events in the
NHS Chaired by the Chief Medical Officer.”
Donaldson L. London: The
Stationery Office; 2000.This report tries to understand the scale and nature of
serious failures in the United Kingdom’s National Health Service (NHS) system,
examine how the NHS might learn from those failures, and recommend methods to
minimize future failures.
Full PDF Version
‘Patient Safety and the “Just Culture”: A Primer for Health Care Executives.’ Marx D. New York, NY: Columbia University; 2001. The author presents
accountability from the legal perspective focusing on four key behavior
concepts: human error, negligence, reckless conduct, and knowing violations.
Full PDF Version
Below are Powerpoint
Presentations which have been presented at CPSC meetings and conferences:
The Colorado Clinical Guideline Collaborative –
Jay Krakovitz, M.D.
Going Beyond the 100K to Improve Clinical
Outcomes and Reduce Mortality - Sue Bond, M.S.,
C.H.E., C.P.H.Q.
How to Get Sued Using Your EMR – Michael S.
Victoroff, M.D
The Path to Safe and Reliable Care – Michael
Leonard, MD
Sorry Works –
Making the Case for Full-Disclosure - Doug
Wojcieszak, MS, Founder, The Sorry Works!
Coalition
Patients for
Patient Safety--Jeni Dingman, WHO World
Alliance for Patient Safety
Making
Zero Injuries a Priority--Kerry O'Connell
Hand Hygiene as a Patient Safety Priority--Laurie
Griffith, RN, Manager of Infection Control at
Denver Health
Initiatives to Improve Healthcare Quality and
Safety--Carolyn Clancy, MD, Director of AHRQ
Culture of Teamwork and Safety in Healthcare--J. Brian
Sexton, Ph.D.
A Statewide Approach to Improving Patient Safety--Beryl Vallejo, Dr.PH, RN Donna Kusuda, RN, MS, & Barbara Jahn, MS
Update on Patient Safety from the Pharmacy Perspective--Larry Clark, Pharm.D., M.S., BCPS
"Can You Hear Me Now?" Communication Between Health Care Professionals and Patient Safety--Kathy Boyle, RN, MS
Creating a Culture of Safety--Michael Leonard, MD
Comprehensive Safe and Reliable Healthcare--Allen S. Frankel, MD
A Team Training Model for Healthcare--Carol
Anne Tarrant, RN, MS, JD and Jeff Varnell, MD, COPIC
Design for the Future:
Work Environments to Promote Safe Nursing Practice--Andrew Kramer, MD
Diane Cookson's PowerPoint Presentation
from August 2004 Meeting Focusing on Patient Safety in New Medical Facilites
Dr.
Kenneth Kizer's 2002 Keynote Speech
Effective Communication Tools
and Skills to Enhance Patient Safety--Michael Leonard, MD
Levels of
Neonatal Care: American Academy of Pediatrics Policy Statement and What It
Means for Colorado--Barbara Hughes, CNM, MS, MBA, FACNM, CPCC Chair 2004-2005
Look, Count, and Ye Shall Find: Data Driven Medication Safety--Tim Lesar, PharmD
Kathy
Boyle's PowerPoint Presentation from August 2004 Meeting Focusing on
Patient Safety in New Medical Facilities
Message in a Bottle: Improving
Medication Safety Through Effective Error Reporting--Matthew Grissinger, RPh
The Value of Accreditation--Kurt A.
Patton, Executive Director, JCAHO Accreditation Services
Understanding the Current Medical
Malpractice Crisis---Troy Brennan, MD, JD, MPH
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