Resources for Nurses
Nursing Conferences
Nursing Topics
Nursing Organizations
Nursing Profession
Nursing Shortage
Resources for Researchers
Research Resources
Nursing Instruments & Measurements
Research Instruments in CINAHL
Survey & Questionnaire Design
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Accountability: Patient Safety and Policy Reform. Edited by Virginia
A. Sharpe. Georgetown University Press. 2004.
Achieving Safe and Reliable Healthcare: Strategies and Solutions.
Michael Leonard, Allan Frankel, Terri Simmonds; with Kathleen Vega. Health
Administration Press. 2004.
Care of Patients: Examples of Compliance. Joint Commission on Accreditation
of Healthcare Organizations. 1999.
A Clinical Focus on Reform. Clinical Advisory Board. The Advisory
Board Company. 2001.
Clinical Governance. John Wright and Peter Hill. Churchill Livingstone.
2003.
Note: Read Chapter 6.
Cockpit Resource Management. Edited by Earl L. Weiner, Barbara
G. Kanki, and Robert L. Helmreich. Academic Press. 1993.
Collaborative Education to Ensure Patient Safety. Council on Graduate
Medical Education & National Advisory Council on Nurse Education and
Practice Joint Meeting, September 13-14, 2000, Washington, DC : Report
to Secretary of U.S. Department of Health and Human Services and Congress.
U.S. Dept. of Health and Human Services, Public Health Service, Health
Resources and Services Administration, Bureau of Health Professions, Division
of Nursing, Division of Medicine and Dentistry. 2000.
Computerized Physician Order Entry: Lessons from Pioneering Institutions.
Advisory Board Company. 2001.
Creating a Secure Workplace: Effective Policies and Practices in Health
Care. Edited by John R. Lion, William R. Dubin, and Donald E. Futrell.
American Hospital Publishing (AHA). 1996.
Crossing the Quality Chasm: A New Health System for the 21st Century.
Committee on Quality of Health Care in America, Institute of Medicine.
National Academy Press, 2001.
Current Research on Patient Safety in the United States. Jeffrey B.
Cooper, Asta V. Sorensen, Susan M. Anderson, Lorri A. Zipperer, Laura
N. Blum, and Jill F. Blim. National Patient Safety Foundation. 2001.
Demanding Medical Excellence: Doctors and Accountability in the Information
Age. Michael L Millenson. The University of Chicago Press. 1997.
Descartes' Error: Emotion, Reason, and the Human Brain. Antonio R.
Damasio. Avon Books, 1995.
Diagnosing and Preventing Adverse and Sentinel Events. John Robert
Dew and Meri E. Curtis. Opus Communications, 2001.
Do It Right the First Time: A Short Guide to Learning from Your Most Memorable
Errors, Mistakes, and Blunders. Gerard I. Nierenberg. John Wiley &
Sons. 1996.
Envisioning the National Health Care Quality Report. Institute
of Medicine. National Academy Press, 2001.
To Err is Human: Building a Safer Health System. Institute of
Medicine. National Academy Press, 2000.
Error Management: An Important Part of Quality Control. Edited by
Jennifer Rhamy. AABB Press, 1999.
Error Reduction in Health Care: A Systems Approach to Improving Patient
Safety. Edited by Patrice L. Spath. AHA Press, 2000.
Essential Issues for Leaders: Emerging Challenges in Health Care.
Joint Commission on Accreditation of Healthcare Organizations. Joint Commission
Resources, 2001.
Escape Fire: Designs for the Future of Health Care. Donald M. Berwick.
John Wiley & Sons, 2004.
Note: Book contains speeches from the Institute of Healthcare
Improvement's National Forum on Quality Improvement in Health Care,
1992-2002. The following speeches are found in the book: Kevin Speaks
(1992), Buckling Down to Changer (1993), Quality Comes Home (1994),
Run to Space (1995), Sauerkraut, Sobriety, and Spread of Change (1996),
Why the Vasa Sank (1997), Eagles and Weasels (1998), Escape Fire (1999),
Dirty Words and Magic Spells (2000), Every Single One (2001), and Plenty
(2002).
Evidence-Based Falls Prevention: A Study Guide for Nurses. Carol
Eldridge. hcPro. 2004.
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction.
Joint Commission on Accreditation of Healthcare Organizations. Joint Commission
Resources, 2002.
Falls in Older People: Prevention & Management. 3rd edition. Rein
Tideiksaar. Health Professions Press. 2002.
Falls in Older People: Risk Factors and Strategies of Prevention.
Stephen R. Lord, Catherine Sherrington, and Hylton B. Menz. Cambridge
University Press. 2001.
The Family as Patient Care Partner: Leveraging Family Involvement to Improve Quality, Safety, and Satisfaction. Advisory Board Company. 2006.
The Field Guide to Human Error Investigations. Sidney Dekker.
Ashgate Publishing Ltd. 2002.
First, Do No Harm: The Cure for Medical Malpractice. Ira E. Williams.
Corinthian Books. 2004.
To Do No Harm: Ensuring Patient Safety in Health Care Organizations.
Julianne M. Morath and Joanne E. Turnbull. Jossey-Bass. 2005.
First Do No Harm: A Practical Guide to Medication Safety and JCAHO
Compliance. Edited by David Beardsley and Kristen Woods. Opus Communications. 1999.
Forgive and Remember: Managing Medical Failure. Charles L. Bosk. Second
edition. The University of Chicago Press. 2003.
Front Line of Defense: The Role of Nurses in Preventing Sentinel Events.
Joint Commission
Resources. 2007.
Guide to Emergency Management Planning in Health Care. Joint Commission
on Accreditation of Healthcare Organizations. 2002.
The Handbook of Patient Safety Compliance: A Practical Guide
for Health Care Organizations. Edited by Fay A. Rozovsky and James
R. Woods, Jr. Jossey-Bass. 2005.
The Handbook on Storing and Securing Medications. Robert J. Weber. Joint Commission Resources. 2006.
Hospital
Nurse Staffing and the Quality of Care. Report from the Agency
for Healthcare Research and Quality. May 2004.
Hospital Patient Safety Standards: Examples of Compliance. Joint Commission
on Accreditation of Healthcare Organizations. 2002.
Human Error. James T. Reason. Cambridge University Press. 1999.
The Impact of Information Technology on Patient Safety. Edited by
Russell F. Lewis. HIMSS. 2002.
Infection Prevention in Surgical Settings. Barbara J. Gruendemann
and Sandra Stonehocker Mangum. W. B. Saunders. 2001.
Informed Infection Control Practice. Rozila Horton and Lynn Parker.
2nd edition. Churchill Livingstone. 2002.
Interdisciplinary Patient Care: Building Teams and Improving Patient Outcomes.
Brenda Gail Summers. HCPro. 2004.
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of
Medical Mistakes. Robert M. Wachter and Kaveh G. Shojania. Rugged
Land. 441 pages. 2004.
Issues in Provision of Care, Treatment, and Services for Hospitals. Joint Commission Resources. 2004.
The JCAHO 2005 National Patient Safety Goals: Successful Strategies
for Compliance. Glenn D. Krasker and Della M. Lin. HCPro. 2004.
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Edited by Ann Page, Committee on the Work Environment for Nurses and Patient
Safety, Board on Health Care Services. National Academies Press. 2004.
Leading a Patient-Safe Organization. Matthew J. Lambert. Health Administration
Press, 2004.
Lessons in Patient Safety. Edited by Lorri Zipperer and Susan
Cushman. National Patient Safety Foundation. 2001.
Limiting Harm in Health Care: A Nursing Perspective. Edited by Frank
Milligan and Kate Robinson. Blackwell Publishing. 2003.
The Logic of Failure: Recognizing and Avoiding Error in Complex Situations.
Dietrich Dorner. Perseus Books. 1996.
Managed Care Organization Nonreporting to the National Practitioner Data
Bank: A Signal for Broader Concern. May 2001.
Management Mistakes in Healthcare: Identification, Correction and Prevention.
Edited by Paul B. Hofmann and Frankie Perry. Cambridge University Press. 2005.
Specific Chapters:
What Medical Errors Can Tell Us About Management Mistakes (Chapter 4,
pg. 74-83)
Medical Errors: Paradise Hills Medical Center [Case Study] (Chapter
7, pg. 119-134)
Managing Quality of Care in a Cost-Focused Environment. Edited
by Norbert Goldfield and David B. Nash. ACPE/Aspen. 1999.
Managing the Risks of Organizational Accidents. James T. Reason. Ashgate. 1997.
Measuring Patient Safety. Edited by Robin Newhouse and Stephanie
Poe. Jones and Bartlett Publishers. 2005.
Medical Error: What Do We Know? What Do We Do? Edited by Marilynn
M. Rosenthal and Kathleen M. Sutcliffe. Jossey-Bass. 2002.
Medial Error and Patient Safety: Human Factors in Medicine. George A. Peters and Barbara J. Peters. CRC Press/Taylor & Francis. 2008.
Medical Errors and Medical Narcissism. John Banja. Jones and Bartlett. 2005.
Medical Staff Performance Improvement. Joint Commission on the
Accreditation of Healthcare Organizations. 2001.
Medication Errors: The Nursing Experience. Zane Robinson Wolf. Delmar.
1994.
Medication Reconciliation Handbook. Joint Commission Resources; American Society of Health-System Pharmacists. 2006.
Medication Safety and Cost Recovery: A Four-Step Approach for Executives.
Chip Caldwell and Charles Denham. Health Administration Press. 2001.
Medication Use: A Systems Approach to Reducing Errors. Edited by Diane
DeMichele Cousins. Joint Commission on Accreditation of Healthcare Organizations. 1998.
Meeting JCAHO's Infection Control Requirements: A Priority Focus Area.
Joint Commission Resources. 2004.
Meeting the Joint Commission's 2007 National Patient Safety Goals. Joint Commission Resources. 2006.
Misadventures in Health Care: Inside Stories. Edited by Marilyn Sue
Bogner. Lawrence Erlbaum Associates, 2004.
Must-Have Information for Nurses about Quality and Patient Safety. Joint Commission Resources. 2007.
Must-Have Information for Physicians about Quality and Patient Safety. Joint Commission Resources. 2007.
Partnering with Patients to Reduce Medical Errors. Edited by Patrice
L. Spath. Health Forum, AHA Press. 2004.
Patient Safety: A Guide to JCAHO Compliance and Beyond. Robert Marder
and Richard A. Sheff. Opus Communications. 2002.
Patient Safety: Achieving a New Standard for Care. Edited by Philip
Aspden, et al. Quality Chasm Series. National Academies Press. 2004.
Patient Safety: Essentials for Health Care. Joint Commission on Accreditation
of Healthcare Organizations. Third edition. Joint Commission Resources. 2005.
The Patient Safety Handbook. Edited by Barbara J. Youngberg and
Martin J. Hatlie. Jones and Bartlett. 2004.
Patient Safety Improvement Guidebook. Patrice L. Spath. Brown-Spath
& Associates, 2000.
Patient Safety Initiative 2000: Spotlighting Strategies, Sharing Solutions:
Compendium of Abstracts October 2000. National Patient Safety Foundation.
2000.
Patient Safety: Principles and Practice. Edited by Jacqueline Fowler
Byers and Susan V. White. Springer. 2004.
The Physician's Promise: Protecting Patients from Harm. Joint Commission
on Accreditation of Healthcare Organizations. 2003.
Preparing to Meet the Joint Commission Patient Safety Goals.
Charles P. Coe and John P. Uselton. American Society of Health-System
Pharmacists. 2004.
Preventing Adverse Events in Behavioral Health Care: A Systems Approach
to Sentinel Events. Joint Commission on the Accreditation of Healthcare
Organizations. 1999.
Preventing Medication Errors. Committee on Identifying and Preventing Medication Errors, Board on Health Care Services. Edited by Philip Aspden , et al. National Academies Press. 2007.
Preventing Medication Errors and Improving Drug Therapy Outcomes: A Management
Systems Approach. Charles D. Hepler and Richard Segal. CRC Press.
2003.
Preventing Medication Errors: Strategies for Pharmacists. Joint Commission
on the Accreditation of Healthcare Organizations. [RM-146.5-.P43-2001x]
Preventing Patient Falls. Janice M. Morse. Sage. [RA-969.9-.M67-1997]
Preventing Sentinel Events in the Environment of Care. Joint Commission
on Accreditation of Healthcare Organizations. 2000.
Profiles in Patient Safety: Lessons from Effective Programs.
Nursing Executive Center, The Advisory Board Company. 2003.
Quality Work Environments for Nurse and Patient Safety. Edited by
Linda McGillis Hall. Jones and Bartlett Publishers. 2005.
Reducing Adverse Drug Events. Lucian L. Leape, Andrea Kabcenell, Donald
M. Berwick, and Jane Roessner. Institute for Healthcare Improvement. 1998.
Reducing Medical Errors and Improving Patient Safety: Profiles of Institutions
and Organizations That Made a Commitment to Change... and a Difference.
National Coalition on Health Care/Institute for Healthcare Improvement.
National Academy Press, 2000.
Risk Management Handbook for Health Care Organizations. Edited
by Roberta Carroll. Jossey-Bass. 2001.
Risk Management in Health Care Institutions: A Strategic Approach.
Florence Kavalier and Allen D. Spiegel. Jones and Bartlett. 2003.
Root Cause Analysis in Health Care: Tools and Techniques. Joint Commission
on Accreditation of Healthcare Organizations. 3rd edition. Joint Commission
Resources. 2005.
Safe Patient Handling and Movement: A Guide for Nurses and Other Health Care Providers. Audrey L. Nelson. Springer Pub. Co. 2006.
Safe Practices for Better Healthcare: A Consensus Report. The National
Quality Forum. 2003.
Safety Facts & More: Providing a Safe Environment for Patients, Staff
and Visitors. Mayo Clinic, 2002.
Safety in the Operating Room. Joint Commission Resources. 2006.
Sentinel Events: Evaluating Cause and Planning Improvement. Joint
Commission on the Accreditation of Healthcare Organizations, 1998.
The Six Sigma Book for Healthcare: Improving Outcomes by Reducing Errors.
Robert Barry, Amy C. Murcko, and Clifford E. Brubaker. Health Administration
Press. 2002.
Smart Nursing: How to Create a Positive Work Environment that Empowers
and Retains Nurses. June Fabre. Springer Publishing. 2005.
Step-by-Step Guide to Effective Root Cause Analysis [Includes Root
Cause Analyst CD-ROM]. Kenneth A. Hirsch and Dennis T. Wallace. Opus Communications,
2001.
The Step-by-Step Guide to Failure Modes and Effects Analysis. Robert
Marder and Richard A. Sheff. Opus Communications, 2002.
10 Powerful Ideas for Improving Patient Care. James L. Reinertsen
and Wim Schellekens. Institute for Healthcare Improvement. 2005.
Using Hospital Standards to Prevent Sentinel Events. Joint Commission
on Accreditation of Healthcare Organizations, 2001.
VA and Defense Health Care: Increased Risk of Medication Errors
for Shared Patients. General Accounting Office. Report Number:
GAO-02-1017. September 2002.
Wall of Silence: The Untold Story of the Medical Mistakes That Kill and
Injure Missions of Americans. Rosemary Gibson and Janardan Prasad
Singh. LifeLine Press, 2003.
What Every Hospital Should Know About Sentinel Events. Joint Commission
on the Accreditation of Healthcare Organizations, 2000.
Working in Interdisciplinary Teams to Improve Patient Care: A Staff Training
Handbook. Brenda Gail Summers. HCPro, 2004.
Working Safe: How to Help People Actively Care for Health and Safety.
E. Scott Geller. Lewis Publishers, 2001.
Workplace Safety. Edited by John Ridley and John Channing. Butterworth
Heinemann. 1999.
Videos
Back to Basics: Applying the Standard Precautions. [1 video].
Nashville, TN: Envision Incorporated, 2003. 15 minutes.
Synopsis: Shows how to use basic infection control measures following
the CDC guidelines for standard precautions. Demonstrates proper hand
hygiene practices, appropriate use of protective equipment, procedures
for routine disinfections of environmental surfaces and spills, and specific
precautions for handling infectious material and sharps.
Beyond Blame. [1 video]. Solano Beach, CA: Bridge Medical, 1998.
9 minutes.
Synopsis: Compilation of interviews on the subject of medication errors
with health care professionals across the U.S., recorded in the fall of
1997.
Charlie Victor Romeo. [1 video]. Boston, MA: The Institute for
Healthcare
Improvement, 2000. 115 minutes. (2000 National Forum on Quality Improvement
in Health Care)
Synopsis: Applies lessons learned from the reenactment of real-life airline
emergencies to reduce medical errors.
Correct Site Surgery Tool Kit: Building a Safer Tomorrow. [1 compact
disc with guide]. Denver, CO: AORN (The Association of periOperative Registered
Nurses), 2004. 38 minutes.
Note: Video on CD-ROM viewable via Windows Media Player; accompanying
materials include directions for independent study activity, policy template,
frequently asked questions, guidelines for implementing JCAHO universal
protocol, resource list, and learner evaluation forms.
Synopsis: Provides infomation on the history, guidelines, and rationale
for patient safety that perioperative nurses can utilize for implementation
of the Joint Commission's universal protocol for preventing wrong site,
wrong procedure and wrong person surgery.
Critical Condition with Hedrick Smith: The Quality Gap: Medicine's
Secret Killer. [1 video]. Princeton, NJ: Films for the Humanities
& Sciences, 2000. 49 minutes. With: Hedrick Smith.
Synopsis: "Pulitzer Prize-winning journalist Hedrick Smith travels
the length and breadth of the United States to critically examine the
quality, affordability, and availability of healthcare. Case studies of
ordinary Americans, supported by thorough medical and academic research,
provide a timely checkup for a medical system that more and more say is
in need of intensive care".
Dateline NBC. A Lesson from Ben: A Dateline Special. [1 video].
New York City, NY: NBC, 2002. 41 minutes. With: Jane Pauley, Stone Phillips,
and John Hockenberry.
Note: 1/1/2002 presentation
Synopsis: This report on the prevalance of medical errors features seven-year-old
Ben who died during a routine operation due to a medication error; describes
the hospital investigation, the action taken to prevent future mistakes,
and the hospital's response to the family.
Dirty Words & Magic Spells. [1 video]. Boston, MA: The Institute
for Healthcare Improvement, 2000. 57 minutes. (2000 National Forum on
Quality Improvement in Health Care) With: Donald M. Berwick.
Every Single One. [1 video]. Boston, MA: Institute for Healthcare
Improvement, 2001. 57 minutes. With: Donald M. Berwick.
Note: 12/11/2001 presentation at the IHI 13th Annual National Forum
Synopsis: The presenter shares his vision for a new health care system
that promises to pursue perfection for every single patient. He features
the Partners in Health program in Carabayllo, Peru as a model; he offers
the Institute for Healthcare Improvement Persuing Perfection grants as
an opportunity to participate in the vision; he uses Crossing the Quality
Chasm, a 2001 report by the Institute of Medicine, as a framework. He
discusses the chain of effect in improving health care quality, ten new
rules for 21st century health care, and techniques for making the new
rules possible.
Everyone Wins! Quality Care Without Restraints. [8 videotapes
with 3 guides]. New York, NY: Independent Production Fund, 1995. 108 minutes.
Part 1: The New Resident (12 minutes)
Part 2: Up and About: Minimizing the Risk of Fall Injuries (14 minutes)
Part 3: Working with Residents Who Wander (13 minutes)
Part 4: Getting Hit, Grabbed, and Threatened: What It Means, What to Do
(14 minutes)
Part 5: Staying Restraint-Free Evenings, Nights, and Weekends (12 minutes)
Part 6: Now That the Restraints Are Off, What Do We Do? (13 minutes)
Part 7: The Management Perspective (16 minutes)
Part 8: A Family Guide to Restraint-Free Care (12 minutes)
First, Do No Harm: A Case Study of Systems Failure. [1 video].
Chicago, IL: Partnership for Patient Safety or Carlsbad, CA: CRM Learning.
Synopsis: The following composite case study is drawn from the malpractice
closed claim files of the Risk Management Foundation of the Harvard Medical
Institutions. Its value lies in its ability to raise awareness and stimulate
dialogue to enhance patient safety and motivate change.
First, Do No Harm: Taking the Lead. [1 video with guide]. Chicago,
IL: Partnership for Patient Safety or Carlsbad, CA: CRM Learning.
Synopsis: This video is a dramatization of how one hospital responds to
an adverse patient event that results from a multi-faceted systems failure.
Built on the situation created in Part 1, the hospital staff involved
in the adverse event (a group of hospital doctors, nurses, administrators,
anesthetist, and others) review the event and decide what they should
do to insure patient safety. Based on clinical case abstracts and analysis
by Risk Management Foundation of the Harvard Medical Institutions.
First, Do No Harm. Part 3: Healing Lives, Changing Cultures. [1
video with guide containing 1 digital video disc ]. Chicago , IL : Partnership
for Patient Safety, 2005. 83 minutes.
Note: Series contains two earlier parts (Parts 1 and 2).
Synopsis: Features a 26 minute dramatization of how one hospital responds
to an adverse patient event that results from a multi-faceted systems
failure. The dramatization is followed by interviews with patient safety
experts and healthcare industry leaders discussing issues, ideas and strategies
for meeting the challenges raised by the story.
FMEA: A Proactive Approach to Reducing Errors. [1 video with guide].
Oakbrook Terrace, IL: Joint Commission Resources, 2002. 22 minutes. With:
Rick Plastine (Host).
Synopsis: Describes the differences between a root cause analysis and
a failure mode and effects analysis; defines failure mode and effects
analysis (FMEA) and its key elements; identifies the purpose of FMEA and
shows how it can be used to reduce risk; describes the specific steps
of FMEA by using a common household task (making a cup of coffee) as an
example of how FMEA can be used in the assessment of a particular process.
The Josie King Story. [1 video]. Baltimore, MD: Johns Hopkins,
2002. 14 minutes. With: Sorrel King.
Note: 10/11/2002 presentation
Synopsis: A mother shares her story about her 18-month old daughter, Josie,
who died at Johns Hopkins as a result of medical mistakes. Includes information
on the founding of the Josie King Pediatric Patient Safety Program at
Johns Hopkins.
Just Culture Summit Keynote. [1 video]. St. Paul, MN: Minnesota
Alliance for Patient Safety, Minnesota Hospital Association, 2004. 49
minutes. With: David Marx.
Note: 4/30/2004 presentation
Synopsis: The purpose of the MAPS Just Culture Summit held April 30, 2004
was to begin developing consensus on how to manage health care professionals
and safety events. In this keynote presentation David Marx provides an
introduction to patient safety, disciplinary action, and just culture.
"Let's Talk": Disclosure After an Adverse Medical Event.
[1 video]. Chicago, IL: National Patient Safety Foundation, 2001. 30 minutes.
Note: Contains excerpts from the third "Annenberg" conference
on patient safety, "Let's talk: communicating risk and safety in
health care," held May 16-18, 2001 at St. Paul, Minnesota.
Synopsis: By using step-by-step instructions on how to disclose medical
errors, this video will demonstrate the importance of disclosure and how
open communication can strengthen the patient-provider relationship.
Little Hope: How Common Sense Thinking Can Lead to a Mess. [1 video].
Boston, MA: The Institute for Healthcare Improvement, 2000. 61 minutes.
(2000 National Forum on Quality Improvement in Health Care) With: Paul
Plsek.
Synopsis: Debunks many commonly-held ideas about leadership; proposes
creative approaches for success in complex systems.
Medication Error Reduction: Achieving Results. [1 video with guide].
Chicago, IL: Joint Commission Satellite Network, 2001. 90 minutes. (2001
Joint Commission Videoconference series). With: Janet Storie Brand (Host),
Darryl S. Rich, Kenneth G. Hermann, and Philip J. Schneider. Note: 3/22/01
presentation.
Synopsis: Identifies the three key steps in the medication use process
(prescribing, dispensing, and administering medications) that are vulnerable
to error and explain why; identifies the potential sources of error during
each of the three steps and be able to explain examples of each; describes
systems to identify errors where they are occuring and mechanisms to analyze
the root causes of error; discuss the importance of creating a non-punitive
corrective action environment that supports the identification of errors
so that replication can be prevented; outline prevention strategies in
the hospital that lead to a safer medication distribution system.
Medication Use: Approaches to Reducing Errors. [1 video with guide].
Chicago, IL: Joint Commission Satellite Network, 1999. 92 minutes. With:
Janet Storie Brand (Moderator), Diane Cousins, David E. Raskin, and Darryl
S. Rich.
National Summit on Medical Errors and Patient Safety Research.
[5 videos]. Sponsored by the Federal Quality Interagency Coordination
(QuiC) Task Force ; Health TV Channel, 2002. 213 minutes. With: John Eisenberg.
Note: Summit held September 11, 2000 at J.W. Marriott Hotel, Washington,
D.C.
Part 1: Broad-Based System Approaches (44 minutes)
Part 2: Consumer and Purchasers (83 minutes)
Part 3: Particular System Issues (27 minutes)
Part 4: Reporting Issues and Learning Approaches (31 minutes)
Part 5: State Coalitions and Public Policy Advocates (28 minutes)
Synopsis: The purpose of this summit is to set priorities for a national
research agenda to address the issue of medical errors and patient safety.
Five panels of experts offer suggestions for what types of research the
government and private sector need to conduct to help reduce and prevent
future errors.
Part 1 recognizes that medical errors are the fault of systems
and not of individuals and seeks to identify how improving patient safety
can be a health care system-wide endeavor. Common themes raised by the
panel include: confidentiality and protection, human factors, organizational/cultural
issues, reporting systems, use of technology, and training of providers.
Part 2 includes opening remarks by John Eisenberg who likens the
problem of medical errors to an epidemic and states that research is necessary
to understand the magnitude of the problem, its causes, and its burden
on people, which will provide information crucial to developing a cure.
Panel 1 includes testimony from consumers and purchasers to highlight
the very real impact of errors on patients and their families, as well
as on those who purchase care on their behalf, and to better understand
this group's research needs.
Part 3 focuses on targeted areas that contribute to the research
agenda on medical errors and patient safety: medication errors, hospital
staffing, medical devices, and end-of-life care.
Part 4 addresses the common problem of two primary stakeholders,
physicians and states, in finding ways to effectively develop reporting
systems that improve the quality of patient care. Common themes include:
defining medical errors, failures of current reporting systems, mandatory
versus voluntary reporting, and appropriate use of technology.
Part 5 covers common concerns of health care providers, accrediting
agencies, professional associations, and other public advocates and the
need for collaboration in order to find solutions to many of the shared
problems with regard to patient safety.
Nursing's Agenda for the Future. [1 video]. Carrollton, TX: PRIMEDIA
Workplace Learning, 2002. 90 minutes. With: Marlene Hilton (Moderator),
Mary Foley, Bobbi Kimball, and Mary Blegen.
Synopsis: The objectives of this program are to be able to describe the
issues relevant to decreased nurse staffing and the predictions for unprecedented
future shortages; explain the challenges faced in recruiting more people
into the nursing profession; discuss the research that identifies the
correlation between high quality nursing care and improved patient outcomes;
describe the strategic plan designed to achieve a desired future state
for the profession of nursing; and identify the ten domains that must
be addressed to bring about positive change for nursing and the healthcare
system.
Part of the Oath: The Physician's Role in Medication Safety. [1 DVD with guide]. Oakbrook Terrace, IL: Joint Commission Resources, 2004. 26 minutes.
Synopsis: This program is a systematic approach to enhancing patient safety through reducing medication errors from a physician's viewpoint.
Patient Safety: A Critical Issue. [1 video with guide]. Nashville,
TN: Envision, 2003. 21 minutes.
Synopsis: Discusses common types of medical errors, reporting and documentation
of sentinel events, conducting root cause analysis, when and how an error
should be disclosed, and creating a culture of safety using process and
systems analysis.
Patient Safety: Your First Concern. [1 video with guide]. Cypress,
CA: Medcom, 2002. 23 minutes.
Synopsis: After completing this course, the learner should be able to
understand the concerns and problems that led to development of the JCAHO
patient safety initiative; identify the six major patient safety goals;
understand and implement 11 key safety measures; and implement a patient
safety program at your institution.
Patients Play a Vital Role in Patient Safety. [1 video]. Philadelphia
, PA : Regional Medication Safety Program for Hospitals, Health Care Improvement
Foundation, 2003. 21 minutes. With: Ronni Solomon and Matthew Fricker.
Note: A collaborative production of the Delaware Valley Healthcare Council,
the Institute for Safe Medication Practices and ECRI. Funded by a grant
from Independence Blue Cross.
Synopsis: Five scenarios encourage patients to become actively involved
and informed participants in their care following six key principles:
sharing vital information with all caregivers; asking questions about
their health problem and care; asking for help from a trusted family member;
expressing concern if something does not seem right; alerting caregivers
if symptoms change; paying attention to instructions and keeping a written
copy of instructions.
Preventing Medication Errors. [1 video with guide]. Springhouse,
PA: Springhouse Corporation, 2001. 30 minutes.
Synopsis: Tells how to safely administer medications, prevent common medication
errors, document medication and report medication errors.
Preventing Medication Errors for the Oncology Nurse. [1 video with
guide]. Lagua Niguel, CA: Stratos Institute for Healthcare Performance,
2000. 42 minutes. (2000 Oncology Nursing Today Series) With: Susan Weiss
Behrend.
Principles of Medication Administration. [1 video with guide].
San Jose, CA: Models of Hope, 2000. 21 minutes.
Pursuing Perfection in Health Care. [7 VHS tapes with guides].
Boston, MA: Institute for Healthcare Improvement, 2004. 140 minutes.
Note: Produced by Crosskeys Media and also supported by the Robert Wood
Johnson Foundation.
Contents:
Part 1 – The Quality Chasm (20 minutes)
Part 2 – Involving Patients in Redesigning Care (20 minutes)
Part 3 – Planning Care for Chronic Disease (20 minutes)
Part 4 – Improving Care at the End of Life (20 minutes)
Part 5 – Engaging Doctors in Redesigning Care (20 minutes)
Part 6 – Safety as a System Property (20 minutes)
Part 7 – Navigating Complex Systems of Care (20 minutes)
Synopsis: This seven-part video series focuses on the goal of improving
patient outcomes by helping health care organizations raise the bar of
performance and by stimulating a will for change. Each video features
a story spotlighting major quality issues in today's health care system.
Reducing Medication Errors Through Failure Mode and Effects Analysis.
[1 video]. Philadelphia, PA: The Center for Proper Medication Use and
Burroughs Wellcome, 1993. 24 minutes.
Synopsis: Presents a technique originally developed by the aerospace industry
in the late 1960's to address the inevitability of human error. This video
shows how failure mode and effects analysis can be adapted to the hospital
environment using a continuous quality improvement approach.
Rx for Preventing Medication Errors. [1 video with guide]. Marblehead,
MA: The Greeley Company, 2000. 9 minutes.
Synopsis: Provides an easy, cost-effective, and memorable way to motivate
staff to think about medication errors and what they can do to help prevent
errors; discusses how to identify systems-related problems that present
medication-safety risks; examines how to make necessary changes to reduce
the risk of medication errors.
Sharps Injury Reduction: A Three-Step Approach to Reducing Sharps Injuries.
[1 video]. Marblehead, MA: The Greeley Company, 2001. 17 minutes.
Synopsis: This program defines the various types of sharps injuries; explains
how the benefits of using safer devices outweigh the initial extra cost;
offers a concrete solution to help reduce the number of sharp injuries;
identifies protential needlestick hazards and show employees how to take
appropriate action to prevent them; and explains the three-step approach
to sharps injury reduction.
Strategies for Leadership: An Invitation to Conversation. [3 videos
with guides]. Boston, MA: Institute for Healthcare Improvement, 2000.
76 minutes. With: Donald M. Berwick, Lucian L. Leape, John E. "Jack" Wennberg, and Susan Edgman-Levitan.
Synopsis:
Part 1: Improving Patient Safety (29 minutes): Delves into the
profiles of errors in care, the consequences in terms of injury to patients,
and the "systems approach" to improving safety. Also addresses
issues in medical culture that can impede or accelerate progress toward
safer care.
Part 2: The Quality Imperative-A Roundtable Discussion (23 minutes):
Explores what is known about the key dimensions of quality in healthcare
from both a technical and the patients' viewpoints, and some of the underlying
causes of defects in care. Discusses specific roles for boards, executives,
and clinical leaders in moving the agenda of quality improvement into
the organization's strategic frame.
Part 3: Patient Service (24 minutes): Explores the experience of
patients through their eyes; reviews the most important dimensions of
service and care as patients and families report it, and suggests how
health care systems and professionals can better approach world-class
levels of service and caring.
Think Twice, Save a Life: The Pharmacy's Role in Medication Safety. [1 DVD with guide]. Oakbrook Terrace, IL: Joint Commission Resources, 2004. 27 minutes.
Synopsis: Includes information, strategies, and tips on preventing medication errors. It also offers ideas for partnering with nurses, physicians, and patients and their families to improve the medication-use process. The workbook includes self-assessment exercises and a list of additional resources for further study.
The list of resources on this page is not intended to be complete or
comprehensive. The selected resources included are representative of the
subject area covered and are an excellent starting point for further research.
Additional print and electronic information can be found by conducting
your own literature search, consulting other library collections, or contacting
a professional librarian/informationist for assistance. Please check with
your local library to determine availability of these resources and local
library access to national interlibrary loan networks for resources not
owned locally. The list of resources is updated regularly as new resources
are identified by the Mayo Clinic Libraries, Mayo Clinic College of Medicine.
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