Excerpt

The articles in this volume provide a number of perspectives on performance and tools used to improve the safe delivery of health care. They include a wide variety of approaches that underscore the importance of teamwork and communication, the incorporation of human factors and ergonomic principles, and the use of various tools and best practices that steer us in the direction of more accurate, increasingly reliable, and safer health care delivery.

Contents

• Preface
• Acknowledgments
• Prologue: The Shift toward Performance and Tools
• Teamwork and Communication
  • TeamSTEPPS^™: Team Strategies and Tools to Enhance Performance and Patient Safety
    Heidi B. King, MS, CHE, James Battles, PhD, David P. Baker, PhD, Alexander Alonso, PhD, Eduardo Salas, PhD, John Webster, MD, MBA, Lauren Toomey, RN, BSBA, MIS, and Mary Salisbury, RN, MSN.
    • Introduction
    • TeamSTEPPS™: A 3-Year R&D Project
    • Summary
    • References
  • Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies
    John S. Webster, MD, MBA, Heidi B. King, MS, CHE, Lauren M. Toomey, RN, BSBA, MIS, Mary L. Salisbury, RN, MSN, Stephen M. Powell, BA, ASO, Brigetta Craft, RN, MSN, DNP, David P. Baker, PhD, and Eduardo Salas, PhD.
    • Introduction: Realities and Harm in the Ambulatory Care Setting
    • Approaches to Improve Quality and Safety in Ambulatory Care
    • Six Promising Tools and Strategies to Improve Quality and Safety in Ambulatory Care
    • Discussion and Conclusion
    • References
  • Building Self-Empowered Teams for Improving Safety in Postoperative Pain Management
    Ranjit Singh, MA, MB, BChir (Cantab), MBA, Bruce Naughton, MD, Diana Anderson, EdM, Donna McCourt, RN, BSN, and Gurdev Singh, MScEng, PhD.
    • Introduction
    • Methods
    • Intervention Design
    • Results
    • Discussion
    • References
  • Beyond Rapid Response Teams: Instituting a “Rover Team” Improves the Management of At-Risk Patients, Facilitates Proactive Interventions, and Improves Outcomes
    Rémi M. Hueckel, MSN, FNP, Jennifer L. Turi, MD, Ira M. Cheifetz, MD, Jane Mericle, RN, MSN, MHS-CL, Jon N. Meliones, MD, MS, and Kshitij P. Mistry, MD, MSc.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Improving Referral Communication Using a Referral Tool Within an Electronic Medical Record
    Tejal K. Gandhi, MD, MPH, Nancy L. Keating, MD, MPH, Matthew Ditmore, David Kiernan, Robin Johnson, Elisabeth Burdick, MS, and Claus Hamann, MD, MS.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Improving Patient Safety Through Provider Communication Strategy Enhancements
    Catherine Dingley, RN, PhD, FNP, Kay Daugherty, RN, PhD, Mary K. Derieg, RN, DNP, and Rebecca Persing, RN, DNP.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Improving Clinical Communication and Patient Safety: Clinician-Recommended Solutions
    Donna M. Woods, EdM, PhD, Jane L. Holl, MD, MPH, Denise Angst, PhD, RN, Susan C. Echiverri, MD, Daniel Johnson, MD, David F. Soglin, MD, Gopal Srinivasan, MD, Julia Barnathan, Laura Amsden, MSW, MPH, Lenny Lamkin, MPH, and Kevin B. Weiss, MD, MPH.
    • Background
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
• Simulation
  • In Situ Simulation: Challenges and Results
    Mary D. Patterson, MD, George T. Blike, MD, and Vinay M. Nadkarni, MD.
    • Introduction
    • Medical-Legal Issues
    • Outcomes Associated with In situ Simulation
    • Conclusion
    • References
  • The Nature, Characteristics and Patterns of Perinatal Critical Events Teams
    William Riley, PhD, Helen Hansen, PhD, RN, Ayse P. Gürses, PhD, Stanley Davis, MD, Kristi Miller, RN, MS, and Reinhard Priester, JD.
    • Background
    • Methods
    • Results
    • Team Behaviors
    • Discussion
    • Implications
    • Conclusion
    • References
  • Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures
    Stanley Davis, MD, William Riley, PhD, Ayse P. Gurses, PhD, Kristi Miller, RN, MS, and Helen Hansen, PhD.
    • Introduction
    • Methods
    • Results
    • Action Plans
    • Discussion
    • References
  • The Mobile Mock Operating Room: Bringing Team Training to the Point of Care
    John T. Paige, MD, Valeriy Kozmenko, MD, Tong Yang, MD, MS, Ramnarayan Paragi Gururaja, MD, Isidore Cohn Jr., MD, Charles Hilton, MD, and Sheila Chauvin, MEd, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Examining the Effectiveness of Debriefing at the Point of Care in Simulation-Based Operating Room Team Training
    Ramnarayan Paragi Gururaja, MD, MPH, Tong Yang, MD, MS, John T. Paige, MD, and Sheila W. Chauvin, MEd, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Effect of Recent Refresher Training on in Situ Simulated Pediatric Tracheal Intubation Psychomotor Skill Performance
    Akira Nishisaki, MD, Louis Scrattish, MD, John Boulet, PhD, Mandip Kalsi, MD, Matthew Maltese, MS, Thomas Castner, Aaron Donoghue, MD, Roberta Hales, RRT, RN, Lisa Tyler, BS, RRT, Peter Brust, RN, Mark Helfaer, MD, and Vinay Nadkarni, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Appendix 1 High Fidelity Infant Simulator Function Utilized in this Study
    • Appendix 2 Simulation Scenario
    • References
  • Simulation-Based Education Improves Patient Safety in Ambulatory Care
    Beth A. LaVelle, PhD, RN, CEN and Joanne J. McLaughlin, MA, BSN, RN.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
• Human Factors
  • Pillars of a Smart, Safe Operating Room
    F. Jacob Seagull, MD, Gerald R. Moses, PhD, and Adrian E. Park, MD.
    • Introduction
    • Conclusion
    • References
  • High-Hanging Fruit: Improving Transitions in Health Care
    Shawna J. Perry, MD, Robert L. Wears, MD, MS, and Emily S. Patterson, PhD.
    • Introduction
    • Conclusion
    • References
  • Minding the Gaps: Creating Resilience in Health Care
    Christopher Nemeth, PhD, Robert Wears, MD, David Woods, PhD, Erik Hollnagel, PhD, and Richard Cook, MD.
    • Introduction
    • Conclusion
    • References
  • Error Producing Conditions in the Intensive Care Unit
    Frank A. Drews, PhD, Adrian Musters, BS, and Matthew H. Samore, MD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • References
  • Patient Monitors in Critical Care: Lessons for Improvement
    Frank A. Drews, PhD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • References
• Tools and Practices
  • Developing the Tools to Administer a Comprehensive Hospital Discharge Program: The ReEngineered Discharge (RED) Program
    Brian Jack, MD, Jeffrey Greenwald, MD, Shaula Forsythe, Julie O’Donnell, Anna Johnson, Lynn Schipelliti, RN, Mary Goodwin, RN, Gail M. Burniske, PharmD, BCPS, Caroline Hesko, Michael Paasche-Orlow, MD, MPH, Christopher Manasseh, MD, David Anthony, MD, MSc, Stephen Martin, MD, MEd, Lindsey Hollister, Margaret Jack, Vimal Jhaveri, Kevin Casey, MPH, and V.K. Chetty, PhD.
    • Introduction
    • Medical Errors and Adverse Events at Hospital Discharge
    • Developing the RED Toolbox
    • The RED Toolbox
    • Testing the RED
    • Conclusion
    • References
  • Creating an Accurate Medication List in the Outpatient Setting Through a Patient-Centered Approach
    Kathryn Kraft Leonhardt, MD, MPH, Patti Pagel, RN, Deborah Bonin, RHIA, CPHQ, D. Paul Moberg, PhD, Mitchell L. Dvorak, MS, and Martin J. Hatlie, JD.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • The Use of Modest Incentives to Boost Adoption of Safety Practices and Systems
    Gregg S. Meyer, MD, MSc, David F. Torchiana, MD, Deborah Colton, James Mountford, MB, BCh, Elizabeth Mort, MD, Sarah Lenz, Nancy Gagliano, MD, Elizabeth Immen, and James Heffernan.
    • Introduction
    • Program Results to Date
    • Conclusion
    • References
  • Using Data Mining to Predict Errors in Chronic Disease Care
    Ryan M. McCabe, Gediminas Adomavicius, PhD, Paul E. Johnson, PhD, Gregory Ramsey, Emily Rund, William A. Rush, PhD, Patrick J. O’Connor, MD, MPH, and JoAnn Sperl-Hillen, MD.
    • Introduction
    • Methods
    • Results
    • Predicting Errors in Synthetic Patient Data
    • Predicting Errors in Clinical Patient Data
    • Conclusion
    • References
  • Venous Thromboembolism Safety Toolkit: A Systems Approach to Patient Safety
    Brenda K. Zierler, PhD, Ann Wittkowsky, PharmD, Gene Peterson, MD, PhD, Jung-Ah Lee, MN, Courtney Jacobson, BA, Robb Glenny, MD, Fred Wolf, PhD, Lynne Robins, PhD, Pamela Mitchell, PhD, Seth Wolpin, PhD, Tom Payne, MD, Paul Hendrie, MD, Geunhye Han, MSN, and Hyunjin Oh, MSN.
    • Introduction
    • VTE Safety Toolkit: What Is It?
    • Methods
    • Results
    • Implementation and Dissemination of Interventions
    • Discussion
    • Conclusion
    • References
  • Using Process Measures to Improve Patient Safety Practices to Prevent Pulmonary Embolism
    Ellen Flink, MBA, Harold Kilburn Jr, MA, John Morley, MD, FACP, Tong Wang, MS, and Robert Panzer, MD, FACP.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • A Tool to Assess Compliance in Anticoagulation Management
    Carla S. Huber, ARNP, James M. Levett, MD, FACS, and Joan M. Atkinson, RN.
    • Background
    • Conclusion
    • References
  • Using Lean Six Sigma^® Tools to Compare INR Measurements from Different Laboratories Within a Community
    Brion Hurley, CSSBB, James M. Levett, MD, FACS, Carla Huber, ARNP, and Tim L. Taylor, SSBB.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Using Six Sigma^® Methodology to Improve Handoff Communication in High-Risk Patients
    Kshitij P. Mistry, MD, MSc, James Jaggers, MD, Andrew J. Lodge, MD, Michael Alton, MSN, RN, Jane M. Mericle, BSN, RN, MHS-CL, Karen S. Frush, MD, and Jon N. Meliones, MD, MS.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • 10-Year Experience Integrating Strategic Performance Improvement Initiatives: Can the Balanced Scorecard, Six Sigma^®, and Team Training All Thrive in a Single Hospital?
    Jon N. Meliones, MD, MS, Michael Alton, MSN, RN, Jane Mericle, BSN, RN, MHS-CL, Richard Ballard, Joseph Cesari, Karen S. Frush, MD, and Kshitij Mistry, MD, MSC.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • References
  • Impact of Staff-Led Safety Walk Rounds
    Vicki L. Montgomery, MD, FAAP, FCCM.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Appendix A Safety walk rounds script
    • References
  • Development of a Web-Based Patient Safety Resource: AHRQ Patient Safety Network (PSNet)
    Niraj L. Sehgal, MD, MPH, Sumant R. Ranji, MD, Kaveh G. Shojania, MD, Russ J. Cucina, MD, MS, Erin E. Hartman, MS, Lorri Zipperer, MA, and Robert M. Wachter, MD.
    • Introduction
    • Site Development
    • Results
    • Future Directions
    • Conclusion
    • References
• Peer Reviewers—Volume 3

Suggested citation:

Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: New directions and alternative approaches. Vol. 3. Performance and Tools. AHRQ Publication No. 08-0034-3. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.