Excerpt

While systems thinking enables new and productive approaches to improving patient safety, it brings with it its own conceptual challenges—challenges that, if not recognized and addressed, will both slow our progress and introduce new harm. These challenges require that we learn more about how to apply systems thinking to health care, through answering such questions as: What are the microsystems and macrosystems in health care? How can their performance be measured? How do they interact? What are their vulnerabilities—and strengths? What are the strengths and weaknesses of each component that comprises the system? How can those strengths and weaknesses compensate for each other within the larger system? How can the functions of each component be optimized so that the results of the system are maximized? How can we identify and monitor for unintended consequences? How can we intervene to prevent harm from unintended consequences? Many of these questions are the direct or indirect foci of the articles in this volume on “Concepts and Methodology.”

Contents

• Preface
• Acknowledgments
• Prologue: Systems Thinking and Patient Safety
• Measurement and Taxonomies
  • Applying Patient Safety Indicators (PSIs) Across Health Care Systems: Achieving Data Comparability
    Peter E. Rivard, A. Rani Elwy, Susan Loveland, Shibei Zhao, Dennis Tsilimingras, Anne Elixhauser, Patrick S. Romano, and Amy K. Rosen.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Validation of AHRQ's Patient Safety Indicator for Accidental Puncture or Laceration
    Brian Gallagher, Liyi Cen, and Edward L. Hannan.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Readmissions for Selected Infections Due to Medical Care: Expanding the Definition of a Patient Safety Indicator
    Brian Gallagher, Liyi Cen, and Edward L. Hannan.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Patient Safety Research in Medical Group Practices: Measurement and Data Challenges
    Amy R. Wilson, Bryan E. Dowd, and John E. Kralewski.
    • Introduction
    • Specifying and measuring group practice variables
    • Measuring patient safety
    • Data sources
    • Conclusions
    • References
  • Developing a Taxonomy for Coding Ambulatory Medical Errors: A Report from the ASIPS Collaborative
    Wilson D. Pace, Douglas H. Fernald, Daniel M. Harris, L. Miriam Dickinson, Rodrigo Araya-Guerra, Elizabeth W. Staton, Rebecca VanVorst, Bennett L. Parnes, and Deborah S. Main.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Taxonomic Guidance for Remedial Actions
    Bruce Thomadsen and Shi-Woei Lin.
    • Introduction
    • Previous taxonometric studies
    • The Madison Medical Taxonomy
    • Conclusions
    • Acknowledgments
    • References
  • The Brighton Collaboration: Creating a Global Standard for Case Definitions (and Guidelines) for Adverse Events Following Immunization
    Katrin S. Kohl, Jan Bonhoeffer, M. Miles Braun, Robert T. Chen, Philippe Duclos, Harald Heijbel, Ulrich Heininger, Elisabeth Loupi, S. Michael Marcy, and The Brighton Collaboration.
    • Introduction
    • Global standardization in immunization safety
    • Conclusions
    • Acknowledgments
    • References
• Surveillance
  • Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency
    David R. Hunt, Nancy Verzier, Susan L. Abend, Courtney Lyder, Lisa J. Jaser, Nancy Safer, and Paul Davern.
    • Introduction
    • Methods
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Medical Injury Identification Using Hospital Discharge Data
    Peter M. Layde, Linda N. Meurer, Clare Guse, John R. Meurer, Hongyan Yang, Prakash Laud, Evelyn M. Kuhn, Karen J. Brasel, and Stephen W. Hargarten.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative
    Daniel M. Harris, John M. Westfall, Douglas H. Fernald, Christine W. Duclos, David R. West, Linda Niebauer, Linda Marr, Javán Quintela, and Deborah S. Main.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Development and Implementation of The University of Texas Close Call Reporting System
    Sharon K. Martin, Jason M. Etchegaray, Debora Simmons, W. Thomas Belt, and Kelly Clark.
    • Introduction
    • Phase one: system development
    • Phase two: consensus about content
    • Phase three: UTCCRS prototype
    • Phase four: implementation
    • Preliminary findings about UTCCRS and conclusion
    • Acknowledgments
    • References
• Medication Safety
  • Translating Patient Safety Research into Clinical Practice
    David J. Magid, Paul A. Estabrooks, David W. Brand, Marsha A. Raebel, Ted E. Palen, John F. Steiner, Eli J. Korner, David W. Bates, Richard Platt, and Russell E. Glasgow.
    • Introduction
    • The RE-AIM framework
    • Evaluating a medication safety program using RE-AIM: an example
    • Conclusion
    • Acknowledgments
    • References
  • Development of a Computerized Adverse Drug Event (ADE) Monitor in the Outpatient Setting
    Andrew C. Seger, Tejal K. Gandhi, Carol Hope, J. Marc Overhage, Michael D. Murray, David Weber, Julie Fiskio, Evgenia Teal, and David W. Bates.
    • Introduction
    • Settings
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors
    Emily Beth Devine, Jennifer L. Wilson-Norton, Nathan M. Lawless, Thomas K. Hazlet, Ryan Hansen, Kerry Kelly, Stephanie Te, and Carolyn Wong.
    • Introduction
    • Practice setting
    • Conducting the study
    • Defining and establishing data elements
    • Creating the study database
    • Data sources
    • Study methods
    • Evaluation methods
    • Refinements
    • Current status of the implementation
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words?
    Dean Schillinger, Edward L. Machtinger, Frances Wang, Lay-Leng Chen, Karen Win, Jorge Palacios, Maytrella Rodriguez, and Andrew Bindman.
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Methodological Challenges in Describing Medication Dosing Errors in Children
    Heather McPhillips, Christopher Stille, David Smith, John Pearson, John Stull, Julia Hecht, Susan Andrade, Marlene Miller, and Robert Davis.
    • Background
    • Barriers to safe pediatric prescribing
    • Conclusions
    • Acknowledgments
    • References
  • Development of a Multipurpose Dataset to Evaluate Potential Medication Errors in Ambulatory Settings
    K. Arnold Chanfor the HMO Research Network CERT Patient Safety Investigators.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
• Cognition, Systems, and Risk
  • Diagnostic Failure: A Cognitive and Affective Approach
    Pat Croskerry.
    • Background
    • Cognitive dispositions to respond (CDRs)
    • Determinants of CDRs
    • Impact of affective state
    • Affective influences on decisionmaking
    • Strategies to overcome CDRs
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Diagnosing Diagnosis Errors: Lessons from a Multi-institutional Collaborative Project
    Gordon D. Schiff, Seijeoung Kim, Richard Abrams, Karen Cosby, Bruce Lambert, Arthur S. Elstein, Scott Hasler, Nela Krosnjar, Richard Odwazny, Mary F. Wisniewski, and Robert A. McNutt.
    • Introduction
    • Traditional and innovative approaches to learning from diagnosis error
    • Diagnosis error case vignettes
    • Lessons and issues raised by the diagnosis error cases
    • Conclusion
    • Acknowledgments
    • References
  • Cognitive Artifacts' Implications for Health Care Information Technology: Revealing How Practitioners Create and Share Their Understanding of Daily Work
    Christopher Nemeth, Michael O'Connor, P. Allan Klock, and Richard Cook.
    • Introduction—the nature of technical work
    • Technical work in groups
    • Understanding how coordination works
    • Operating in the operating room suite
    • Making it work on the day of surgery
    • The future of cognitive artifacts and technical work
    • Conclusions: reaching for discovery
    • Acknowledgments
    • References
  • Clinical Inertia and Outpatient Medical Errors
    Patrick J. O'Connor, JoAnn M. Sperl-Hillen, Paul E. Johnson, William A. Rush, and George Biltz.
    • Introduction
    • Operational definition of clinical inertia
    • Prevalence and cost of clinical inertia
    • What are the causes of clinical inertia?
    • Promising approaches to reduce clinical inertia
    • Barriers to improving clinical inertia
    • Methodological challenges in clinical inertia research
    • Conclusion
    • References
  • A Conceptual Framework for Studying the Safety of Transitions in Emergency Care
    Ravi Behara, Robert L. Wears, Shawna J. Perry, Eric Eisenberg, Lexa Murphy, Mary Vanderhoef, Marc Shapiro, Christopher Beach, Pat Croskerry, and Karen Cosby.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • Evaluating and Predicting Patient Safety for Medical Devices with Integral Information Technology
    Jiajie Zhang, Vimla L. Patel, Todd R. Johnson, Philip Chung, and James P. Turley.
    • Introduction
    • Heuristic evaluation
    • Extended hierarchical task analysis
    • An example of extended hierarchical task analysis
    • Conclusion
    • Acknowledgments
    • References
  • Work System Analysis: The Key to Understanding Health Care Systems
    Ben-Tzion Karsh and Samuel J. Alper.
    • Introduction
    • Work system analysis
    • Conclusions
    • Acknowledgments
    • References
  • Observing Nurse Interaction with Infusion Pump Technologies
    Pascale Carayon, Tosha B. Wetterneck, Ann Schoofs Hundt, Mustafa Ozkaynak, Prashant Ram, Joshua DeSilvey, Brian Hicks, Tanita L. Robert, Myra Enloe, Rupa Sheth, and Sade Sobande.
    • Introduction
    • Methods
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Usability Testing and the Relation of Clinical Information Systems to Patient Safety
    Michelle L. Rogers, Emily Patterson, Roger Chapman, and Marta Render.
    • Introduction
    • Background
    • Methods
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation
    David Anthony, VK Chetty, Anand Kartha, Kathleen McKenna, Maria Rizzo DePaoli, and Brian Jack.
    • Introduction
    • Methods
    • Conclusion
    • Acknowledgments
    • References
  • Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities
    Sharon Conrow Comden, David Marx, Margaret Murphy-Carley, and Misti Hale.
    • Introduction
    • Methods
    • Discussion
    • Conclusions
    • Acknowledgments
    • References
  • A Model-based Approach to Prioritizing Medical Safety Practices
    Richard S. Marken.
    • Background
    • Methods
    • “Wind tunnel” tests
    • Results
    • Conclusion
    • Acknowledgments
    • References
• Safety Culture and Organizational Issues
  • Creating a Culture of Patient Safety through Innovative Hospital Design
    John G. Reiling.
    • Introduction
    • Methods
    • Putting it all together
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • From Science to Service: A Framework for the Transfer of Patient Safety Research into Practice
    Veronica F. Nieva, Robert Murphy, Nancy Ridley, Nancy Donaldson, John Combes, Pamela Mitchell, Christine Kovner, Elizabeth Hoy, and Deborah Carpenter.
    • Introduction
    • Background
    • Knowledge creation and distillation
    • Diffusion and dissemination
    • End user adoption, implementation, and institutionalization
    • Conclusions and implications
    • Acknowledgments
    • References
  • Making a Case for Organizational Change in Patient Safety Initiatives
    Rangaraj Ramanujam, Donna J. Keyser, and Carl A. Sirio.
    • Introduction
    • Patient safety through the looking glass of organizational change
    • Observations about change management processes in patient safety initiatives
    • Conclusions
    • Acknowledgments
    • References
  • Organizational Climate of Staff Working Conditions and Safety—An Integrative Model
    Patricia W. Stone, Michael I. Harrison, Penny Feldman, Mark Linzer, Timothy Peng, Douglas Roblin, Jill Scott-Cawiezell, Nicholas Warren, and Eric S. Williams.
    • Introduction
    • The integrative model
    • Results
    • Discussion
    • Acknowledgments
    • References
  • A Conceptual Model for Disclosure of Medical Errors
    Stephanie Fein, Lee Hilborne, Margie Kagawa-Singer, Eugene Spiritus, Craig Keenan, Gregory Seymann, Kaveh Sojania, and Neil Wenger.
    • Introduction
    • Methods
    • Results
    • Conclusion
    • Acknowledgments
    • References
• Peer Reviewers—Volume 2

Suggested citation:

Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in patient safety: from research to implemtation. Vol. 2, Concepts and methodology. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005.

Disclaimer: The authors of the papers published in this document are responsible for the content of each paper. Statements in the papers should not be construed as endorsements by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.