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Uncategorized

Editor’s Notebook: On the Internet, Nobody Knows You’re a Patient

September 1, 2008 ‐ Leslie Proctor

Increasingly, healthcare consumers engage with clinicians and administrators in discussions about improving the safety and quality of healthcare.

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Uncategorized

From Punitive Action to Confidential Reporting. A Longitudinal Study of Organizational Learning from Incidents

September 1, 2007 ‐ Leslie Proctor

Common sense and practical experience dictate that organizations with effective reporting systems are able to learn from smaller mishaps and incidents so as to forestall serious workplace accidents (Reason, 1997; Connell, 1998; Johnson, 2001; 2001; Sullivan, 2001).

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Uncategorized

Peer Review: How 2007 Joint Commission Standards Expand Hospital Peer Review

September 1, 2007 ‐ Leslie Proctor

The 2007 medical staff standards of The Joint Commission change the peer review process by strengthening and extending it.

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Uncategorized

Why Worry About Near Misses?

September 1, 2007 ‐ Leslie Proctor

Imagine you’re a nurse on the Code Team, rushing to respond to a patient who has just gone into cardiac arrest.

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Uncategorized

Mishap Mansion: A Patient Safety “House of Horrors”

September 1, 2007 ‐ Leslie Proctor

One of the biggest challenges in improving patient safety is engaging staff members to learn and accept new behaviors.

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Uncategorized

Medical Team Training: Improving Communication in Healthcare

September 1, 2007 ‐ Leslie Proctor

Though studies continue to show that communication failure is a major cause of adverse medical events, we decided to test this relationship by reviewing the experience of the Veterans Health Administration, a large integrated health system.

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Uncategorized

Building a Culture of Safety

September 1, 2007 ‐ Leslie Proctor

The healthcare industry is held increasingly to a standard of flawless performance in an environment where it can be very difficult to manage human error.

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Uncategorized

Critical Care Safety Essentials

September 1, 2007 ‐ Leslie Proctor

The critical care setting is one of the most complex environments in a healthcare facility.

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Uncategorized

Reducing Complexity: A Strategic Approach to Optimizing the Medication Use Process for All Medications

September 1, 2007 ‐ Leslie Proctor

The 2006 Institute of Medicine (IOM) report, Preventing Medication Errors, found that patients experience more than 400,000 adverse drug events (ADEs) annually (IOM, 2006).

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Uncategorized

AHRQ – Emergency Pharmacists: A New Road to Medication Safety

September 1, 2007 ‐ Leslie Proctor

Preventing medication errors, which account for nearly 20% of adverse events overall and affect about 4% of all hospital stays, has become a high-profile goal among national and international patient safety advocates, healthcare organizations, and healthcare providers (IOM, 2000).

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