Unraveling Diagnostic Error: Delving Deeply to Identify Hidden Human Factors

The challenges we face in improving patient safety and decreasing healthcare-related harm and death remain urgent, compelling, and undeniable. Despite our considerable efforts over the past 15 years, and some very notable advances, mostly resulting from increased standardization of processes and the use of checklists, the overall magnitude of the problem remains enormous.

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Health IT & Quality: How to Keep Score

In this age of Yelp®, TripAdvisor®, and Amazon®, product reviews greatly influence which items consumers purchase. Anyone who buys regularly online understands over time the validity of various product reviews and learns how to apply a personal algorithm to cut through to meaningful product information while ignoring prefabricated, biased content.

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Editor’s Notebook: Learning to Work Together

Two articles in this issue are part of an ongoing series about interprofessional and multidisciplinary education in healthcare. Most authors are members of the Institute for Healthcare Improvement’s Open School community (www.ihi.org/openschool), which offers alternative learning opportunities, and online training in quality improvement and patient safety.

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A Model for Simulation-Based Interprofessional Team Learning

In April 2014, students from Wright State University (WSU)’s Boonshoft School of Medicine and College of Nursing and Health teamed up with pharmacy students from Cedarville University—all based in Ohio—to participate in an extracurricular activity they hoped would herald a new approach to their combined curriculums.

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Client Satisfaction Surveys to Improve Outcome Management in Mental and Behavioral Health

The Liberty QualityCare Client Satisfaction Survey is designed to provide an annual measurement of outcomes for a national, private, physician-owned corporation established in 1986. Liberty Healthcare Corporation provides healthcare management and staffing for acute care behavioral health, mental health, dual diagnosis with intellectual/developmental disabilities, correctional mental health, and primary care settings.

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Improving Safety and Reducing Harm from Fluoroscopy

Fluoroscopy is a powerful tool that has been used over the past century in many medical disciplines. If asked, ”What is an X-ray?” many patients would say it is like a photograph—a picture of a body taken at a moment in time. Following this analogy, if a conventional X-ray is similar to a photograph, fluoroscopy is like a video.

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Special Advertising Section: Barcoding

When the Buick plant in Flint, Michigan, demonstrated in 1969 that automatic identification could be done with laser-based barcode readers even on a moving assembly line, many industries took notice. Unfortunately, healthcare wasn’t one of them.

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