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RESOURCES: PATIENT SAFETY NEWS TRACKER ARCHIVES 2003

Also see NPSF Bibliography 2003

• December Monthly Information
• National Academy for State Health Policy: Medical Malpractice and Medical Error Disclosure: Balancing Facts and Fears
• Managed Healthcare Executive
  • Schaller Anderson CEO Joe Anderson says blocking and tackling are what healthcare needs the most
  • Wellness programs move to the forefront
  • Cost control pressures spotlight DM and cost effectiveness
  • Pay for performance programs gain promise in the quest for quality
• Materials Management: 4-minute heroes
• H&HN
  • "Can you hear me Now?"
  • Pressures converge in the ICU
  • Reinventing the VA
• Quality Digest: First Aid for Health Care
• DOH (UK): Working together to reduce Healthcare Associated Infection in England
• December Daily Information
• Boston Globe: Hospital launches assault on errors-Children's strives to change culture  December 23, 2003
• AHRQ: HHS Issues National Reports on Quality and Disparities in the Use of Health Care Services   December 22, 2003
  • QualityTools Web Site
  • National Healthcare Disparities Report: Summary
  • National Healthcare Quality Report: Summary
  • Washington Post: Two U.S. Reports Assess Health Care System
• Los Angeles Times: Drugs And Obesity Drive Trends In 2004 December 22, 2003
• Modern Healthcare: Guarding against IV errors December 22, 2003
• The Wall Street Journal" Who Gets Healthcare? Rationing In An Age Of Rising Costs December 22, 2003
• Chicago Tribune: Hospitals may get dose of merit pay December 21, 2003
• Tennessean: VUMC study tries new tactic to cut health-care costs December 21, 2003
• BMJ December 20, 2003
  • The power of stories over statistics
  • Audit of soap usage by a primary care team
    Snakes, ladders, and spin
  • How to make a silk purse from a sow's ear—a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians
  • How to make a compelling submission to NICE: tips for sponsoring organisations
  • HARLOT plc: an amalgamation of the world's two oldest professions
  • Get Peered!
• LA Times: King/Drew Failure Cited in 3rd Death  December 19, 2003
• AP: Medical Error Kills Young Cancer Patient December 19, 2003
• ISMP: 2003 Cheers! December 18, 2003
• AHRQ: Making the Health Care System Safer: Second Annual Patient Safety Research Conference December 16, 2003
• BCG: A Growing Epidemic: Patients "Miss" Doses of Prescribed Drugs on Purpose December 15, 2003
• AHRQ: Task Force Working Group Encourages Patient-Provider Partnership in Making Decisions About Preventive Care   December 15, 2003
• Baltimore Sun: From tragedy, a quest for safer care December 15, 2003
• Baltimore Sun: How medical errors took a little girl's life December 14, 2003
• BMJ December 13, 2003
  • New plan launched to tackle Britain's high rate of hospital infection
  • Adverse events in surgery in Scotland show a steady fall
  • Treating nicotine addiction
  • Putting the research into practice
• HealthLeaders: Realities and Boundaries in Revitalizing Primary Care: Part 2 December 12, 2003
• Associated Press: Medicare Law Gives Bonuses for Good Care December 11, 2003
• Health Affairs: Addressing Variations: Is There Hope For The Future? December 10, 2003
• AMNews December 8, 2003
  • National CME pilot getting good reviews
  • Physician works to improve health care for everyone
  • ACOG: Ask why patient wants surgery
  • Wellness programs ignored by employees
  • Patient safety: Separating misinformation from truth
  • Kicking butt: Primary care physicians can help smokers quit
• The Indianapolis Star: Database to link local hospitals: Trailblazing system to launch in 2004 would store, expedite residents' health info December 8, 2003
• Modern Healthcare: The evidence is in: Error patterns underscore patient-safety priorities December 8, 2003
• Baltimore Sun: For hospitals, dirty hands still a danger December 8, 2003
• AP: Despite years of warnings, same drugs lead medication error lists December 8, 2003
• Richmond Times Dispatch: Reporting medical errors December 8, 2003
• Federal Register: Agency Information Collection Activities: Proposed Collection; Comment Request December 5, 2003
• NY Times: Hospitals Say They're Penalized by Medicare for Improving Care December 5, 2003
• WSJ: New Medicare legislation seeks to close quality gap December 4, 2003
• HealthLeaders: Realities and Boundaries in Revitalizing Primary Care: Part 1  December 3, 2003
• FREEP: Ford exec gets new task: Solve health care crisis December 3, 2003
• JCAHO: Leading Medical, Health Care Groups Endorse Joint Commission’s New Universal Protocol To Prevent Wrong Site Surgery December 2, 2003
  • Statement by Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality, on JCAHO Surgical Protocol
• NY Times: That Ounce of Prevention Grew Too Big December 2, 2003
• AMNews December 1, 2003
  • Congress told to think globally on disease threat
  • Agreement may boost disease management
  • Office physicians more open to hospitalists
  • Cutting medical errors means systems, money
• November Monthly Information
• Virginia Business: Operation Safety: New programs cut medical errors and improve patient care
• Leapfrog Group: Comment needed on existing and new 'Leaps'
• FP Report: Meeting takes new tack on patient safety
• HealthPlan: 9 Ways To Reduce Unwarranted Variation
• Family Practice Management
  • The Chivalrous Physician
  • When Your Patients Are in Mourning
• Mckinsey Quarterly: How businesses can combat global disease
• Health Affairs: Paying For Performance: Medicare Should Lead
• Pediatrics: Keeping Children Out of Hospitals: Parents’ and Physicians’ Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided
  • Reminders to parents could lower kids' hospital admissions
• HealthLeaders
  • Health Leaders Speak Out
  • Medical Errors: Taking On Mistakes
• JHQ
  • Setting Up QI Programs for Pediatric Specialty Clinics
  • Improving Continuity of Care: Success of a Behavioral Health Program
• NIHCM: "Celebrating a Decade of Difference", which highlights NIHCM's 10 years in health care policy
• November Daily Information
• NY Times: As Obesity Rises, Health Care Indignities Multiply November 29, 2003
• BMJ November 29, 2003
  • Using socioeconomic evidence in clinical practice guidelines
  • Coronary heart disease prevention: insights from modelling incremental cost effectiveness
  • Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data
  • Lessons for the NHS from Kaiser Permanente
• NEJM: Surgeon Volume and Operative Mortality in the United States November 27, 2003
  • Daily Health Policy Report: Mortality Rates Lower Among High-Volume Surgeons, Study Finds
  • AHRQ: New Study Suggests that Death Rates for Some Cardiac and Cancer Surgeries May Be Linked to Surgeons' Experience
• U.S. Commerce Department: President and Commerce Secretary Announce Recipients of Nation’s Highest Honor in Quality and Performance Excellence November 25, 2003
  • Baptist Hospital, Inc., Pensacola, Fla
  • Saint Luke’s Hospital of Kansas City, Kansas City, Mo
• American City Business Journal: Minnesota hospitals act to prevent medical mistakes November 25, 2003
• Buyers Health Care Action Group: New Patient Safety Survey Results Show Local Hospitals Taking Important Steps To Share Information With Consumers November 25, 2003
• AM News: Managing multiple conditions: A challenge for Medicare November 24, 2003
• USP: NCC MERP Supports Principles for Patient Safety Reporting Programs November 24, 2003
• Bowling Green Daily News: Patients’ rights group gets in gear November 23, 2003
• BMJ November 22, 2003
  • Beyond doing
  • Monitoring drug treatment
  • Joining the DoTS: new approach to classifying adverse drug reactions
  • Continuity of care: a multidisciplinary review
• AHRQ To Support Health Information Technology Projects To Improve Patient Safety and Quality Of Care November 21, 2003
• IOM: Patient Safety: Achieving a New Standard for Care  November 20, 2003
  • AHRQ: Statement by Carolyn M. Clancy, M.D., on IOM Report, Patient Safety: Achieving a New Standard for Care
  • Information Week: Institute of Medicine Report Urges Technology Standards For Health Care
  • Washington Post: Doctors Advised to Keep Records Electronically
  • Knoxville News: Report urges sharing of medical information
• JCAHO: Joint Commission Names 2003 Ernest A. Codman Award Winners November 20, 2003
  • Baptist Medical Center Earns Joint Commission's 2003 Ernest A. Codman Award
  • Cleveland Clinic Health System Earns Joint Commission's 2003 Ernest A. Codman Award
  • Linda Aiken, Ph.D., Earns Joint Commission’s 2003 Ernest A. Codman Award
• Treating Tobacco Use and Dependence: A How-To Guide for Implementing the Public Health Service Clinical Practice Guideline November 20, 2003
  • You Can Quit Smoking: There Has Never Been a Better Time to Quit
• Pittsburgh Post-Gazette: Merck CEO wants businesses to work to fix health system November 19, 2003
• USP Releases Fourth Annual Report on Medication Errors  in U.S. Hospitals  November 18, 2003
  • WSJ: Study finds increase in medication errors at U.S. hospitals
• New York Times: Providing Care, When the Cure Is Out of Reach November 18, 2003
• Washington Post: Nursing A Lousy Image November 18, 2003
• AMNews November 17, 2003
  • Incentives lower costs of e-prescribing
  • CME at hand: Information you need, when you need it
• SF Chronicler: On the record: George Halvorson Kaiser CEO looks at the high cost of health care  November 17, 2003
• UnitedHealth: Annual Report Reveals 1.4 Percent Improvement in Nation’s Overall Health Since 2002 Edition; Shows 16.9 Percent Improvement Since 1990  November 17, 2003
  • Full Report: America's Health: State Health Rankings - 2003 Edition
  • USA Today: We have a tie in the healthiest-state category
• BMJ November 15, 2003
  • The criminalisation of fatal medical mistakes
  • How many conditions can a GP screen for?
  • Booking patients for hospital admissions: evaluation of a pilot programme for day cases
  • BMJ: Retrospective analysis of evidence base for tests used in diagnosis and monitoring of disease in respiratory medicine
• JCAHO: JCAHO Approves Strengthened Infection Control Standards November 14, 2003
• ISMP: A spectrum of problems with using color  November 13, 2003
• Denver Post: Nurses' workload tied to errors November 12, 2003
• American Academy of Family Physicians: Partners for Patients: Family Physicians + Industry = Electronic Health Records November 12, 2003
• The Salt Lake Tribune: Medical errors pose deadly threat November 11, 2003
• NY Times: Some Heart Patients Don't Get Basic Care November 10, 2003
• Washington Post: Is Obesity A Disease? November 10, 2003
• Rocky Mountain News: Speakout: Safer health care is less costly, too November 10, 2003
• Archives of Internal Medicine: Body Mass Index in Middle Age and Health-Related Quality of Life in Older Age: The Chicago Heart Association Detection Project in Industry Study November 10, 2003
• Archives of Internal Medicine: Favorable Cardiovascular Risk Profile in Middle Age and Health-Related Quality of Life in Older Age November 10, 2003
• CDC MMWR: Receipt of Cardiac Rehabilitation Services Among Heart Attack Survivors --- 19 States and the District of Columbia, 2001  November 7, 2003
• Medical Economics: "I didn't know I was suing you!" November 7, 2003
• NY Times: Heart Laser Treatment Used Mostly on Patients Who Don't Meet the Federal Criteria November 6, 2003
• Consumers Advancing Patient Safety: Consumers Propose to Make US Healthcare System Safe, Compassionate, and Just November 6, 2003
• Health Affairs: The Relationship Between Technology Availability And Health Care Spending November 5, 2003
• IOM: Keeping Patients Safe: Transforming the Work Environment of Nurses November 4, 2003  
  • Full Report
  • NY Times: Report Cites Danger in Long Nurses' Hours
• Annals of Internal Medicine: The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients November 4, 2003
• Boston Globe: Many children hospitalized needlessly November 4, 2003
• AHRQ: AHRQ Awards Nearly $4 Million in Challenge Grants to Help Hospitals Improve Patient Safety November 3, 2003
• GAO: Information Technology: Benefits Realized for Selected Health Care Functions November 3, 2003
  • Full Report
• Atlanta Business Journal: States' medical error reporting poor, study says November 3, 2003
  • NASHP: How States Report Medical Errors to the Public: Issues and Barriers
• BMJ: Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study November 1, 2003
• American Family Physician: Adverse Drug Reactions: Types and Treatment Options  November 1, 2003
• October Monthly Information
• NIHCM: Accelerating the Adoption of Preventive Health Services: Building New Partnerships and Community Commitment
• HealthLeaders: CPOE's Slow Start
• October Daily Information
• CDC MMWR: Prevalence of Selected Risk Factors for Chronic Disease --- Jordan, 2002 October 31, 2003
• AHRQ: Call for Papers Advances in Patient Safety: From Research to Implementation October 30, 2003
• AHRQ: Managing Care for Adults with Chronic Conditions October 30, 2003
• ISMP: Double-checks for endogenous and exogenous errors  October 30, 2003
• Fox News: The Doctor Shrugged October 30, 2003
• Boston Globe: Hospitals report increase in errors October 29, 2003
• Pennsylvania Health Care Cost Containment Council: Complications/Infections Result In Thousands Of Hospital Readmissions And Millions In Hospital Charges
  • Full Report October 29, 2003
  • Post-Gazette: Report: Patient readmissions to hospitals costly, preventable
• Health Affairs: Politics, Technology, And Transformation: A Conversation With Newt Gingrich October 29, 2003
• California HealthCare Foundation: California Hospitals Committed to Reducing Medication-related Errors October 28, 2003
  • Full Report
• UCLA: Study Examines Well-being of California’s 3.6 Million Seniors; Latinos, Those with Limited-English Report Poorest Health October 28, 2003
• The Tennessean: Insurers hope hospital rankings make customers better shoppers October 28, 2003
• Washington Post: HHS Web Guidelines Created With Designers, Users in Mind  October 27, 2003
• NAHIT: U.S. Electronic Health Record Development Creates Model for Public-Private Healthcare Collaborations  October 27, 2003
• AMNews: Former Bush official seeks drastic quality improvement October 27, 2003
• AMNews: Safety of office-based surgeries questioned October 27, 2003
• AMNews: Georgia PPO to use claims database to assess quality October 27, 2003
• NY Times: Do Some Pay Too Little for Health Care? October 26, 2003
• GAO: State and Federal Oversight of Drug Compounding by Pharmacies October 23, 2003
• ABC News: Cleanliness Issues Famous Reporter's Routine Procedure Turned into Horrible Death, Family Says October 23, 2003
• NEJM: Hospital Use and Survival among Veterans Affairs Beneficiaries October 23, 2003
  • USA Today: Health care quality unaffected by shorter hospital stays
  • NEJM: Medical Care -- Is More Always Better?
• Miami Herald: Political, medical leaders support national data network  October 22, 2003
• CHCF: Opportunities and Challenges Remain When Implementing Electronic Medical Records October 21, 2003
• Adding up quality standards October 20, 2003
• AHA News: Evidence-based medicine is a hot topic, but what does it mean? October 20, 2003
• AMNews: Blues to study its own "best practices"  October 20, 2003
• Philadelphia Business Journal: Chronicling medical errors  October 20, 2003
• Oregonian: Prevention is the best cure; then stop frivolous lawsuits October 20, 2003
• CDC MMWR: Notice to Readers: Publication of Health, United States, 2003 with Chartbook on Trends in the Health of Americans October 17, 2003
  • Health, United States, 2003
• Survey on high-alert medications Differences between nursing and pharmacy perspectives revealed  October 16, 2003
• Portland Press Herald: Hospital: Error led to death of patient  October 16, 2003
• WHA: More than 100 Wisconsin Hospitals to Share Quality, Safety Information CheckPoint SM Tells Consumers What to Expect from Health Care Providers  October 15, 2003
  • Wisconsin Hospital Association Checkpoint Quality Accountability Initiative
• American Family Physician: Reducing Cardiovascular Disease Risk in Patients with Type 2 Diabetes: A Message from the National Diabetes Education Program October 15, 2003
  • Patient information: "Diabetes and Heart Disease"
  • Editorial: "Strategies to Improve Diabetes Care"
• Leapfrog Group: Patient Safety Survey Results Show the Leapfrog Group Gaining National Momentum October 14, 2003
• Guardian: A tragedy of errors  October 14, 2003
• Oregonian: Diagnosis, treatment, but no cure   October 14, 2003
• AP: Hospitals ignore infection precautions  October 13, 2003
• VHA Study Indicates Appropriate Use of Antibiotics Could Save More than $1 Billion Annually and Reduce Complications for Hospitalized Patients October 13, 2003
  • Full Report
• BMJ   October 11, 2003
  • An extreme failure of concordance
  • Prescribing and taking medicines
  • The challenge of concordance
• AHRQ: Case Study Finds Computerized ICU Information System Can Significantly Reduce Time Spent by Nurses on Documentation October 10, 2003
• Forward: Prescribe Standardization for Sick Health Care System October 10, 2003
• CDPH: 100% of State’s Hospitals Participating in National Hospital Reporting Initiative October 9, 2003
  • Frequently Asked Questions
• Modern Healthcare: Voluntary quality program not good enough: Scully October 9, 2003
  • CMS Hospital Quality Initiative (HQI)
  • Virginia Hospitals Participating
  • AHA: Progress of the Quality Initiative
  • AHA: Web site on quality launched as more than 1,700 hospitals take the pledge
  • JCAHO: Statement From The Joint Commission On Accreditation Of Healthcare Organizations Regarding The National Voluntary Hospital Reporting Initiative
• Center for Studying Health System Change: Disease Management: A Leap of Faith to Lower-Cost,Higher-Quality Health Care  October 9, 2003
  • Press Release
  • AMNews: Evidence still out on disease management as cost saver
• JAMA: Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization October 8, 2003
  • AHRQ Press Release: Injuries in Hospitals Pose a Significant Threat to Patients and a Substantial increase in Health Care Costs
  • USA Today: Medical injuries wreak havoc beyond patients' pain and suffering
  • UPI: Medical Injuries Kill 32,000 Annually
  • AP: Med Complications May Cost $9B Per Year
• JAMA: Safety of Patients Isolated for Infection Control   October 8, 2003
• JAMA: Looking for Medical Injuries Where the Light Is Bright  October 8, 2003
• Boston Globe: How HMOs improved health care October 6, 2003
• AMNews:  Are patients safe now? Reviews mixed on progress October 6, 2003
• NY Times: New York's Vital Signs  October 5, 2003
• The Post-Standard: Proposed medical error law raising debate October 4, 2003
• AHRQ: Pocket Guide to Good Health for Adults  October 4, 2003
  • press release
• BMJ: Courses, cadavers, and counsellors: reducing errors in the operating theatre October 4, 2003
• AHA: A Public Resource on Hospital Performance Launch of Clinical Web Site   October 2, 2003
• ISMP: Helping to remove the barriers to patient education   October 2, 2003
• GAO: Medical Malpractice Insurance, Multiple Factors Have Contributed to Premium Rate Increases  October 1, 2003
• September Monthly Information
• NPSF: Focus on Patient Safety
• HealthLeaders Roundtable: Care Management, Balancing Costs and Quality
• JHQ: A Quality Mix: Using Evidence and Experience to Evaluate New Technologies
• Atlanta Business Journal  three-part series on hospital quality and safety that investigates the ongoing, bitter debate over how much information, including hospital performance and patient safety data, the public should have access to September 8, 2003
  • Other states tell consumers more about hospital problems
  • Momentum building to require hospitals to reveal more data
  • Hospitals can be dangerous
  • Inside hospitals, a climate of fear
  • Debate rages over safety: Hospitals, officials, lawyers, employers and consumers wrangle over what public should be told about medical errors
  • State rules hide errors from public
  • Punishment is not goal of regulatory agencies
• Health Affairs: Pittsburgh Regional Healthcare Initiative: A Systems Approach For AMilbank Quarterly: Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Carechieving Perfect Patient Care
  • Pittsburgh Post-Gazette Health-care initiative wins national notice 10
• Milbank Quarterly: Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Care
• September Daily Information
• Aetna: New Aetna Product Features Network Option Based on Quality and Cost-Effectiveness  September 30, 2003
• NY Times: Leading Hospitals Under Fire for Errors September 29, 2003
• AMNews: Minnesota, Pennsylvania to launch error-reporting systems September 29, 2003
• AMNews: Patient safety initiatives turn focus toward primary care September 29, 2003
• The Daily Pennsylvanian: System aims to reduce medical error September 29, 2003
• The Anchorage Daily News: Hospitals strengthen anti-infection efforts  September 29, 2003
• BMJ  special theme Communicating Risk September 26, 2003
  • Communication and miscommunication of risk: understanding UK parents' attitudes to combined MMR vaccination
  • How can doctors communicate information about risk more effectively?
  • Influence of the law on risk and informed consent
  • Commentary: informed consent and risk communication in France
  • Commentary: communicating risk in the United Kingdom
  • Risk communication in practice: the contribution of decision aids
  • Simple tools for understanding risks: from innumeracy to insight
  • Strategies to help patients understand risks
  • Effects of communicating individual risks in screening programmes: Cochrane systematic review
  • Communicating risks
  • The role of risk communication in shared decision making
  • Patients' understanding of risk
  • Teaching medical students and doctors how to communicate risk
  • Making sense of risk information on the web
  • The Quality Enforcer
• Boston Globe: Hospital baby mix-up renews old fears September 26, 2003

• WSJ: Too many patients never reap the benefits of great research September 26, 2003

• Duke Press Release: CMS Accepts Duke Hospital's Corrective Action Plan; Officials Announce Wide-Ranging Measures to Strengthen Patient Safety  September 25, 2003

  • News Observer: Duke again under scrutiny  September 26, 2003

  • Herald Sun: Duke Hospital vows emphasis on safety  September 26, 2003

  • Herald Sun: Duke Hospital faces federal safety sanctions; vows change   September 25, 2003

• WSJ: Hospitals push to improve quality of intensive care  September 25, 2003
• Richmond Times Dispatch: Diagnosing a hurricane Health officials track visits September 24, 2003
• JAMA: Educational Levels of Hospital Nurses and Surgical Patient Mortality  September 24, 2003
• ECRI: ECRI Develops Web-Based Risk Assessment Tool to Support Medication Safety Practices September 24, 2003
• AHA: Legal Concerns with JCAHO Periodic Performance Review September 23, 2003
• NY Times: Beyond the Blame: A No-Fault Approach to Malpractice   September 22, 2003
• Archives of Internal Medicine: Valuing the Outcomes of Treatment, Do Patients and Their Caregivers Agree?   September 22, 2003
• Washington Post: For Medicine, a Growing Problem Doctors, Hospitals, ERs Struggle to Handle Wave of Obese Patients  September 22, 2003
• HealthGrades: Hospital Care Quality Differs Markedly by State, Says Annual HealthGrades Hospital Quality in America Study    September 22, 2003
  • Full Report
• Missouri: Holden Names Patient Safety Commission to Help Reduce Medical Errors in Missouri  September 22, 2003
• Children's Hospital Boston story
  • CHB: Press Statement Regarding the Patient Cases Reviewed by the DPH and CMS at Children's Hospital Boston   September 19, 2003
  • CHB: Children's Hospital's Corrective Actions   September 19, 2003
  • CHB: Q & A for Families Regarding Patient Safety   September 19, 2003
  • Boston Globe: Doctors were unsure of roles as boy died at Children's  September 19, 2003
  • Boston Globe: Children's Hospital scrutinized Patient's case spurs questions, leads to review by Mass., US  September 18, 2003
• NCQA: New Report Finds Health Care System’s "Quality Gaps" Cause 57,000 Deaths Annually  September 18, 2003
  • WSJ: 'Quality gap' in healthcare kills 57,000 each year in U.S.
• ISMP: How sterile water bags show up on nursing units    September 18, 2003
• Philadelphia Inquirer: Helping hospitals get 'where they have to go'    September 17, 2003
• Philadelphia Inquirer: Aiding patient safety with bar codes    September 17, 2003
• AHRQ: HHS, VA Launch Patient Safety Training Program   September 16, 2003
• Annals of Internal Medicine: Standardized Reporting of Clinical Practice Guidelines: A Proposal from the Conference on Guideline Standardization September 16, 2003
• AHA Quality Advisory: A Message to America’s Hospitals: Patient Safety: Improving Hand Hygiene through Safe Use of Alcohol-based Hand Rubs  September 16, 2003
• Kansas City Star: Area hospitals to make data public  September 16, 2003
  • Healthy Kansas  September 16, 2003
• Washington Post: Family Shattered by Blood Mix-Up   September 8, 2003
• BMJ: The importance of patient preferences in treatment decisions—challenges for doctors   September 6, 2003
• JCAHO: Joint Commission and National Quality Forum Announce the 2003 John M. Eisenberg Patient Safety Awards September 5, 2003
• HealthLeaders: Quality Improvement in Independent Practice Part 2: Solutions  September 5, 2003
• ISMP: Cultural diversity and medication safety  September 4, 2003
• Pediatrics: The Effect of Computerized Physician Order Entry on Medication Errors and Adverse Drug Events in Pediatric Inpatients  September 3, 2003
• CIO: CIOs play a critical role in patient safety at hospitals September 3, 2003
• AMNews: Doctors push for more patient safety program funding  September 1, 2003
• August Monthly Information
• Family Practice Management: Practical Evidence-Based Internet Resources  
• IHI Continuous Improvement
• JCOM: Bridges to excellence: building a business case for quality care
• August Daily Information
• BMJ: Thou shalt write legibly  August 30, 2003
• Washington Post: Patient Dies From Blood Mismatch August 29, 2003
• ECRI: Wrong-Site Surgery Prevention Advice from ECRI's Risk Management Experts August 28, 2003
• Health Leaders: Improving Care in Independent Practice August 25, 2003
• AMNews: Bill suggests new ways to handle malpractice cases August 25, 2003
• BMJ: Quality improvement perspective and healthcare funding decisions August 23, 2003
• BMJ: Ethnicity, equity, and quality: lessons from New Zealand August 23, 2003
• ISMP: Is an antithyroid or antimetabolite needed?   August 21, 2003
• Pioneer Press: State's hospitals must report errors August 20, 2003
• Annals of Internal Medicine: Patient Safety and Medical Malpractice: A Case Study  August 19, 2003
• NEJM: Trial Design and Patient Safety — The Debate Continues  August 19, 2003
• Archives of Internal Medicine: Quality Assessment of a Collaborative Approach for Decreasing Drug-Related Morbidity and Achieving Therapeutic Goals August 11, 2003
• BMJ: Involving patients in medical education August 9, 2003
  • editorial: Speak Up!
• ISMP: How are you preventing acetaminophen overdoses? August 7, 2003
• July Monthly Information
• Health Forum Journal
  • The Business Case for Quality
  • Public Performance
• Health Affairs: The Medical Liability Crisis Of 2003: Must We Squander The Chance To Put Patients First?
• HealthLeaders: Pursuing Patient Safety
• AHRQ WebM&M
  • Bleeding Risk
  • Check the Wristband
  • Feeling No Pain
  • A Little Shuteye
  • Code Status Confusion
• July Daily Information
• Washington Post: Invisible Injuries We need a better system for tracking and preventing medical errors  July 29, 2003
• ISMP: Part II - How to prevent errors - Safety issues with patient-controlled analgesia July 24, 2003
• ACP: ACP Urges Congress to Provide for Federal Investment in Standards-Based Health Care Information Technology in the Patient Safety and Quality Improvement Act, S. 720  July 23, 2003
• AMNews: The power of an apology: Patients appreciate open communication July 21, 2003
• Herald-Sun: Drug errors prompt study July 20, 2003
• Milwaukee Journal Sentinel: A blueprint for patient safety July 18, 2003
• AHA Quality Advisory: The Quality Initiative: A Public Resource on Hospital Performance Update on Collaborative Effort July 18, 2003
• IOM: Report Brief. Academic Health Centers: Leading Change in the 21st Century July 17, 2003
• HealthLeaders: Educating the Healthcare Consumer versus Information Overload July 17, 2003
• HHS, Premier announce new initiative to improve, reward healthcare quality July 17, 2003
• DPH Issues Quality of Care Program Report July 16, 2003
  • Full Report
• Archives of Internal Medicine: The Impact of Health Information on the Internet on the Physician-Patient Relationship: Patient Perceptions July 14, 2003
• ISMP: Safety issues with patient-controlled analgesia Part I - How errors occur July 10, 2003
• AMNews: Connecticut releases error report amid flurry of doubts July 7, 2003
• BMJ: The case for knowledge translation: shortening the journey from evidence to effect July 5, 2003
• Annals of Internal Medicine: Computer Physician Order Entry: Benefits, Costs, and Issues July 1, 2003
• HHS Launches New Efforts to Promote Paperless Health Care System July 1, 2003
• June Monthly Information
• MedPac: Report to the Congress: Variation and Innovation in Medicare
• Annals of Family Medicine inaugural issue (lots of quality and patient safety articles)
• AHRQ WebM&M
  • Inapt Antibiotic Use
  • Missed Appendicitis
  • Not a Miscarriage
  • XL or Smaller?
  • The Dangerous Detour
• ACP Observer
  • Don't forget to tap a major safety resource: your patients
  • Seven simple steps to prevent outpatient drug errors
• Premier Safety Share
• Family Practice Management: Focusing on Today's Visit
• JHQ
  • Tracking and Improving Influenza Immunization Rates in a High-Risk Medicare Beneficiary Population
  • A Model Structure for an EBM Program
  • What Quality Improvement Professionals Need to Know About IRBs
• June Daily Information
• NEJM: The Quality of Health Care Delivered to Adults in the United States   June 26, 2003
  • RAND Press Release | Fact Sheet
  • USA Today: 50/50 chance of proper health care
  • Washington Post: Medical care often not optimal, study finds
• ISMP: New data monitoring technology offers real-time reporting of impending adverse events   June 26, 2003
• RAND: Landmark Study Finds American Adults Often Fail To Get Recommended Care, Posing "Serious Threats" To Health June 25, 2003
  • Full Study
  • ABC News: ‘Advanced But Not Reliable’
• Health Affairs: AHCPR And The Changing Politics Of Health Services Research  June 25, 2003
• JCAHO Sentinel Event Alert: Preventing surgical fires June 24, 2003
• Archives of Internal Medicine: Medication Errors in Hospitalized Cardiovascular Patients  June 23, 2003
• BMJ: Anecdotes as evidence June 21, 2003
• Wall Street Journal: Hospitals get new bedside manner June 20, 2003
• NEJM: Improving Safety with Information Technology June 19, 2003
  • Errors Today and Errors Tomorrow
• JCAHO: Comments Sought On Proposed Protocol For Eliminating Wrong Site, Wrong Procedure, Wrong Patient Surgery June 19, 2003
  • Universal Protocol Draft
• Annals of Internal Medicine (new section on quality and patient safety) June 17, 2003
  • Error, Blame, and the Law in Health Care—An Antipodean Perspective
  • Improving Patient Care
  • Patient Safety and the Reliability of Health Care Systems
• Hidden Costs, Value Lost: Uninsurance in America June 17, 2003
• June 16-20, 2003 National Health Care Risk Management Week
• ISMP: Blood pressure monitor tubing may connect to IV ports June 12, 2003
• AHRQ: Testimony on Patient Safety: Supporting a Culture of Continuous Quality Improvement Hospitals and Other Health Care Organizations June 11, 2003
• JCAHO: Joint Commission President Testifies Before U.S. Senate On Critical Strategies For Reducing Medical Errors  June 11, 2003
• Commonwealth Fund: Key to Controlling Health Care Costs Lies with ‘Supply Side’ of Health System  June 11, 2003
  • Executive Summary
• Modern Healthcare: A rewarding relationship  June 9, 2003
• AHRQ: Improving Patient Safety In Rural Hospitals: A Workshop With Wisconsin Health Care Leaders  June 6, 2003
• Minnesota Department of Health: Gov. Pawlenty signs legislation creating new system for reporting adverse events in hospitals  June 6, 2003
• AHRQ: Patient Safety Problems In Hospitalized Children Are Substantial June 2, 2003
• AHA: Quality Advisory: Disclosure of Unanticipated Events June 2, 2003
• May Monthly Information 

• Hospital & Health Networks Special Report on Quality

• Family Practice Management: Group Visits 101
• Family Practice Management: Evidence-Based-Medicine Tools for Your Palm-Top
• AHRQ WebM&M
  • The Dropped Lung
  • Bloody BP Cuff
  • Ectopic or Not?
  • Central Line Clot
  • Suicidal Man with Gun
• May Daily Information 

• AHA Testimony: Hospital Quality and Consumer Information May 29, 2003

• ISMP: Mind your “Medrols”  May 29, 2003
• Hartford Courant: Hospitals Report Mistakes To State May 28, 2003
• NQF: A Comprehensive Framework for Hospital Care Performance Evaluation May 22, 2003
• ISMP: How fast is too fast for IV push medications? May 15, 2003
• NQF: Safe Practices for Better Healthcare May 22, 2003
• Health Affairs: National Medical Spending Attributable To Overweight And Obesity: How Much, And Who's Paying? May 14, 2003
• The Hartford Courant: Hospital That Puts Patients First Sees Success May 12, 2003
• USP: Reducing Medical Errors: A Review of Innovative Strategies to Improve Patient Safety"--Roger L. Williams M.D.  May 8, 2003
• Medscape: Improving Patient Safety: Challenges Abound, but Signs of Progress Are Evident  May 6, 2003
• Miami Herald: Study finds healthcare error prone  May 6, 2003
• AMNews: AHRQ supporters fight funding cuts again May 5, 2003
• AHA: The Quality Initiative: A Public Resource on Hospital Performance May 2, 2003
• ISMP: Nix the quick fix: Drug protocols require groundwork May 1, 2003
• April Monthly Information 
• Family Practice Management
  • THE INTEGRATED SUMMARY: A Documentation Tool to Improve Patient Care
  • Malpractice crisis spreads; legislation pending • Physicians, patients have differing views on disclosing errors • Practice pearls 
• Pediatrics: Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients
  • note: the April issue contains a special supplement on Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The NIC/Q 2000 Experience
• AHRQ WebM&M
  • Another Fall
  • Which End is Which?
  • Premature or Overdue?
  • Medication Overdose
  • The 2-Week Itch
• April Daily Information
• AMNews: Quality care not tied to financial return April 28, 2003
• AMNews: IOM considers licensing, medical education reforms April 28, 2003
• AMNews: The value of volume: Insurers decide more is better April 21, 2003
• LA Times: Series of Errors Led to Girl's Death, State Says April 21, 2003
• BMJ April 19, 2003
  • Improving the quality of health care: Methods for incorporating patients' views in health care
  • Evaluating computerised health information systems: hard lessons still to be learnt
• ISMP: "Looks" like a problem: ephedrine - epinephrine April 17, 2003
• JAMA: Disseminating Innovations in Health Care April 16, 2003
• AHRQ: Your Medicine: Play It Safe April 14, 2003
• BMJ April 12, 2003
  • Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial
  • Primary care in the United States: Innovations in primary care in the United States • Commentary: What can primary care in the United States learn from the United Kingdom? 
  • Improving the quality of health care: Research methods used in developing and applying quality indicators in primary care
• Hartford Courant: Anthem, Providers Launch Safety Initiative April 10, 2003
• Kaiser: Health Care Marketplace | Group of Large Employers To Offer Physicians Bonuses for Quality Care  April 10, 2003
• AHRQ:  To Support Challenge Grants To Assess Risks to Patients and Implement Safe Practices  April 9, 2003
  • Grant Information
• Modern Healthcare: After industry feedback, Leapfrog softens standards  April 9, 2003
• IOM: Health Professionals' Education Must Be Overhauled To Ensure Safety, Quality of Care  April 8, 2003
  • Full Report
• NY Times: When a Patient Is Lost in the Translation  April 8, 2003
• Sun Tallahassee: Medical errors a thorny issue April 6, 2003
• Milwaukee Journal Sentinel: Getting hospitals wired, Bill would reward state hospitals that invest in new computer systems April 6, 2003
• BMJ: Improving the quality of health care, Using research to inform quality programmes April 5, 2003
• The Detroit News: New guidelines change medicine: Doctors use lists as reference for treatments April 4, 2003
• ISMP: U cnt abbrv “Patient Safety” April 3, 2003
• JAMA: Drug-Drug Interactions Among Elderly Patients Hospitalized for Drug Toxicity April 2, 2003
• JCAHO to Shift to Unannounced Surveys by 2006 April 2, 2003
• USA Today: Medical mistakes happen when safeguards fail  April 1, 2003 
• March Monthly Information
• National Academy for State Health Policy: Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors
• Health Affairs (Quality: Where is the Incentive) March/April 2003
  • Making The Business Case For Quality
  • Employers & Quality: Determinants Of Success
  • Hospitals' Error Disclosure Practices
  • The Silence On Clinical Quality Failure
  • The AHRQ Research Challenge
  • Competition Law & Quality
  • Leapfrog Standards
  • Publicizing Hospital Performance
• NASHP: Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors
• American Family Physician: Graham Center One-Pager --Consequences of Medical Errors Observed by Family Physicians
• Family Practice Management
  • Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk
  • Maintaining a Medication List in the Chart
• Pediatrics
  • Hospital-Reported Medical Errors in Children
    • AP: Study Examines Children's Medical Errors
  • Use of an Electronic Medical Record Improves the Quality of Urban Pediatric Primary Care
• March Daily Information 
• AMNews: House passes patient safety bill; voluntary reporting key March 31, 2003 
• Raleigh News Observer: Malpractice fight brews March 30, 2003 
• Charlotte Observer: Health professionals' errors very often go unreported March 30, 2003 
• BMJ: Ethnographic study of incidence and severity of intravenous drug errors   March 29, 2003
• LA Times: UC System to Track Medical Errors   March 28, 2003
• Charlotte Observer: Probes into Jesica's death fault hospital   March 27, 2003
• HealthLeaders: Building Bridges Across the Chasm    March 26, 2003
• USP Posters  March 24, 2003
  • Medication Errors in the Operating Room
  • Medication Errors in Day Surgery Settings
  • Medication Errors in Post Anesthesia Care Units
• ISMP: Last week was National Patient Safety Week – and what a week it was!  March 20, 2003
• Palm Beach Post: Patient safety proposals eclipsed by fight over caps March 20, 2003
• Washington Post: Tips for Self-Protection March 18, 2003
• Milwaukee Journal Sentinel: Hospitals, doctors planning to release quality-of-care data by end of year March 17, 2003
• FDA Medwatch: Avonex (Interferon beta-1a)  March 13, 2003 
• FDA Medwatch: Procrit (epoetin alfa)  March 13, 2003 
• FDA Proposes Bar Codes for Drugs, Blood; New Adverse Reaction Reporting March 13, 2003 
  • NPSF: Food and Drug Administration Plan Focuses on Patient Safety and Reducing Medication Errors  
  • LA Times: FDA Proposes Bar Coding for Hospital Medications 
  • NY Times: F.D.A. Requires Bar Codes on Drugs
  • Washington Post: Bar Codes on Drugs Proposed: Errors Could Be Cut By Matching Hospital Patient, Prescription
• AHRQ: New AHRQ Web-based Tool Offers Hospitals Quick Checkup on Patient Safety March 13, 2003 
• USP: USP Identifies Leading Medication Errors in Hospital Emergency Department Tips Offered for Preventing Medication Errors in Fast-Paced, Urgent Care Situations March 12, 2003
• NPSF: 5th Annual NPSF Patient Safety Congress Looks at Safety from Nine Points of View... March 11, 2003
• NY Times: Do Spelling and Penmanship Count? In Medicine, You Bet  March 11, 2003 
• AMNews: Doctor involvement key to success of computerized order entry  March 10, 2003  
• AHA Quality Advisory: National Patient Safety Awareness Week--Communication and Partnership: Safety Starts with Us March 9, 2003
• ISMP: The virtues of independent double checks – they really are worth your time!  March 6, 2003  
• Joint Commission Urges Consumers To 'Speak Up' During National Patient Safety Awareness Week, March 9 - 15 March 6, 2003  
• IOM: Problems Arising From Lack of Health Insurance Ripple Through Whole Communities March 6, 2003
  • Summary
  • Report
• JAMA  March 5, 2003  
  • Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting
  • Medication Safety: Moving From Illusion to Reality
• AHRQ: Outpatient Prescription Drug-Related Injuries Are Common in Older Patients, but Many Can Be Prevented  March 4, 2003
• Philadelphia Business Journal: Blue Cross aids program aimed at patient safety March 3, 2003
• February Monthly Information
• AAMC: Patient Safety and Graduate Medical Education
• Annals of Internal Medicine: The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care
• Annals of Internal Medicine: The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care 
• Managed Healthcare Executive: Clamping down on variation
• Annals of Internal Medicine: The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital 
  • Summary for Patients
  • NY Times: Patterns: Medical Errors, for Outpatients
  • AP: Study Looks at Effects of Medical Mistakes
  • Washington Post: Medical Errors Come Home Mistakes Grow After Release From Hospital
• Boston Magazine: The Silent Treatment
• IHI Continuous Improvement
• Trustee Magazine
  • What You Can Do: The Trustee, Patient Safety, and JCAHO
  • Putting Safety In The Blueprint
  • Patient Safety^BPOC Technology
• Health Data Management
  • CPOE: Order from Chaos
  • Engineering Patient Safety
• HIMSS: Leveraging IT to Improve Patient Safety F2003
• ACP: Tips to talk to patients in terms they'll understand
• Pediatrics: Are Hospital Characteristics Associated With Parental Views of Pediatric Inpatient Care Quality?
• AHA: Strategies for Leadership: Evidence-based Medicine for Effective Patient Care
• AHRQ WebM&M
  • Patient Mix-Up
  • Unexplained Apnea Under Anesthesia
  • Procedural Mishap: Learning Curve?
  • Flying Object Hits MRI
  • When “Psychiatric” Symptoms are Not
• February Daily Information 
• Federal Register: Medicare Program; Demonstration: Capitated Disease Management for Beneficiaries With Chronic Illnesses  February 28, 2003   
• JAMA  February 26, 2003   
  • Patients' and Physicians' Attitudes Regarding the Disclosure of Medical Errors
    • Seattle Times: Patients want their doctors to admit errors
    • Star-Ledger: What patients want, doctors fear giving
    • University of Washington Press Release: Doctors should consider providing more information to patients about medical errors
  • Improving Quality and Reducing Disparities Toward a Common Pathway 
  • Impact of Quality Improvement Efforts on Race and Sex Disparities in Hemodialysis 
  • Reducing Waiting and Delays in Primary Care 
  • Improving Timely Access to Primary Care, Case Studies of the Advanced Access Model 
• Washington Post: Medical Checks and Balances   February 26, 2003   
• ABC2: FDA to Use Early-Warning Drug System  February 26, 2003   
• Archives of Internal Medicine: Physician, Public, and Policymaker Perspectives on Chronic Conditions  February 24, 2003  
• AMNews  February 24, 2003  
  • CMS project to measure physician quality of care
  • Get your patient involved in treatment decision-making
• Forbes: Lethal Confusion February 24, 2003  
• FDA Medwatch: Permax (pergolide mesylate)  cardiac valvulopathy involving one or more valves in patients receiving Permax therapy February 24, 2003  
• Baltimore Sun: Reforms for patient safety listed as critical February 21, 2003  
• AHRQ: AHRQ Launches New Web-Based Quality Measures Resource February 20, 2003  
  • National Quality Measures Clearinghouse
• ISMP: It’s time for standards to improve safety with electronic communication of medication orders  February 20, 2003  
• FDA Medwatch: Rapamune (sirolimus) bronchial anastomotic dehiscence, including fatal cases, in lung transplant patients treated with Rapamune in combination with tacrolimus and corticosteroids.  February 20, 2003  
• CDC: CDC Reports Pregnancy-Related Deaths Still Higher in Black Women than White Women February 20, 2003
• Duke Transplant Error Story February 20, 2003  
  • National Patient Safety Foundation Statement: Duke University Incident 
  • Duke University Medical Center News
  • Time Magazine: Learning from a Tragic Transplant Mistake
  • 60 Minutes: Anatomy Of A Mistake
  • MSNBC: New chance for teenager given wrong organs  
  • Washington Post: Surgical Expertise, Undone by Error
  • Washington Post: Teenage Girl in Botched Organ Transplant Dies
  • Washington Post: Girl Has Second Transplant After Error
  • Washington Post: Hospital Had Data Before Transplant Error
  • NY Times: Mistakes Even at Elite Hospitals
  • NY Times: Girl in Transplant Mix-Up Dies After Two Weeks
  • NY Times: Girl in Donor Mix-Up Undergoes 2nd Transplant
  • NY Times: An Ethical Dilemma With Few Precedents
  • NY Times: Jésica Was One of 80,000 on Organ Waiting List
  • Charlotte Observer: Probes into Jesica's death fault hospital
  • Charlotte Observer: Elite hospitals err like small ones
  • Charlotte Observer: Was Duke transplant error a violation of medical ethics?
  • The Duke Chronicle: Transplant mixup sees lasting effects
  • The Duke Chronicle: Duke Hospital accreditation falls
  • News Observer: Duke Hospital probe widens 
  • News Observer: Reports critical of Duke staff
  • News-Observer: Duke caught in PR quagmire Medical center defends its handling of news about Jesica 
  • News-Observer: At odds over Jesica's last hours 
  • News-Observer: Mourners pay tribute to Jesica
  • News-Observer: State plans autopsy of transplant patient
  • News-Observer: Jesica dies of brain damage
  • News-Observer: Transplant patient's new heart beating on its own 
  • News-Observer: Hospital, surgeon struggle to recover
  • News-Observer: Second transplant gives teen a chance
  • News-Observer: Transplant patient faces new problem 
  • News-Observer: Duke admits transplant error
  • News-Observer: Organ groups point at Duke
  • News-Observer: Duke admits transplant error
  • News-Observer: Donor site: Organs labeled
  • News-Observer: Mistake alleged in blood match
  • News-Observer: Girl's miracle fleeting
  • Herald Sun: Duke speaks out on Jesica tragedy : Transplant chief tells '60 Minutes' policy failure may have led to death
  • Herald Sun: Duke Medical Center inspected : Accrediting group visits in the wake of Jesica transplant
  • Herald Sun: Hospital offers transplant details : Duke-trained doctor helped get organs
  • Herald Sun: Medical chief offers Jesica details to staff : Duke's Snyderman, Jaggers decline interviews, except for '60 Minutes'
  • Herald Sun: Suit brought in liver mismatch : 17-month-old girl died after lab mixed up blood types of parents
  • Herald Sun: System helps hide hospitals' mistakes : Arbitration, settlements shield errors from public
  • Herald Sun: Mentor defends Duke’s Jaggers
  • Herald Sun: Text of Duke's Jesica Santillan memo from Ralph Snyderman
  • Herald-Sun: Lawyer: Parents didn’t give consent
  • Herald-Sun: Setback as teen's brain swells 
  • Herald-Sun: Rating agency calls for probe of tragic Duke transplant error
  • Herald Sun: Error unlikely to scar Duke ’ s reputation
  • Herald Sun: Statement from Duke surgeon
• AMNews: A just-the-facts approach to quality  February 17, 2003  
• NY Times: A Doctor's Bonus Could Also Help the Patients  February 16, 2003  
• BMJ  February 15, 2003
  • ABC of learning and teaching in medicine: Evaluation
  • Lesson of the week: Fatal dysnatraemia caused by elective colonoscopy 
• AHRQ AHRQ: Tools and Resources for Better Health Care  February 13, 2003
• Medwatch: Serzone (nefazodone HCl) - Medication errors reported due to name confusion between Serzone and Seroquel  February 13, 2003
• La Times: Unsterile Devices Prompt Warnings  February 13, 2003
  • Olympus: Important Safety Notice Regarding Reprocessing the Auxiliary Water Channel
• AHRQ: AHRQ Announces New Web-Based Medical Journal with Patient Safety Lessons Drawn from Actual Cases  February 12, 2003
  • WebM&M (Morbidity and Mortality Rounds on the Web)
• Archives of Internal Medicine   February 10, 2003
  • Depression and Adverse Drug Reactions Among Hospitalized Older Adults
  • Outcomes of Chronic Heart Failure 
  • Improving the Quality of Care for Patients With Pneumonia in Very Small Hospitals 
  • Pneumonia: Still the Old Man's Friend? 
• HIMSS: Patient Safety Top Concern For Healthcare It Executives  February 10, 2003
  • Final Survey
• AMNews  February 10, 2003
  • Doctors pull plug on paperless system
  • IOM quality study targets 20 priority areas
• NY Times: Study Finds Many Doctors Performing Surgery Lack Practice  February 8, 2003
• BMJ  February 8, 2003
  • "Weak" safety culture behind errors, says chief medical officer 
  • Managing communication with young people who have a potentially life threatening chronic illness: qualitative study of patients and parents 
  • ABC of learning and teaching in medicine: Problem based learning 
• United Hospital Fund: Reports Inpatient Services on the Rise in New York City February 6, 2003
  • NY Times: Study Sees Signs of a Rise in Hospital Patients
• ISMP: The reports are in…or are they? Awareness of medication error reporting programs needs a boost February 5, 2003
• Boston Globe: Repetition makes best surgeons, studies find February 5, 2003
• Washington Post: Director Seeks 'Just the Facts' To Improve Medical Care February 5, 2003
• Commonwealth Fund: Academic Health Centers Must Modernize to Preserve Vital Missions February 4, 2003
  • press release
• NY Times: Behind Walkout by Doctors, Chronic War With Lawyers February 3, 2003
• Society of Critical Care Medicine: Particular Subgroups of Premature Neonates Most Likely to Suffer From Medical Errors February 1, 2003
• Society of Critical Care Medicine: ICU Plays Major Role in Care of Terminally Ill Children February 1, 2003
• Society of Critical Care Medicine: DNR Order Does Not Affect Overall Quality of Care in ICU February 1, 2003
• January Monthly Information
• Perspectives on Patient Safety: 2003 JCAHO National Patient Safety Goals: Practical Strategies and Helpful Solutions for Meeting These Goals
  • JCAHO: New National Patient Safety Goals Take Effect January 1 For All Joint Commission-Accredited Organizations 
  • JCAHO: National Patient Safety Goals - FAQs
• VHQC Annual Report 2002
• Archives of Pediatric and Adolescent Medicine: Incidence and Impact of Adverse Drug Events in Pediatric Inpatients
• Journal of the American College of Cardiology: The underutilization of cardiac medications of proven benefit, 1990 to 2002
• FDA Patient Safety News Broadcast
• Commonwealth Fund: Exploring Consumer Perspectives on Good Physician Care: A Summary of focus Group Results
• HIMSS Newsletter
• msJama: Special Issue on Communications
  • Patient-Physician Communication
  • Communication Skills Education in Medical School and Beyond
  • Cultural Diversity: An Evolving Challenge to Physician-Patient Communication
  • Risk Communication: Problems of Presentation and Understanding
  • Advance Directives and Patient-Physician Communication
• January Daily Information 
• National Academy of Social Insurance: Medicare in the 21st Century: Building a Better Chronic Care System January 31, 2003
  • PRESS RELEASE: Blue Ribbon Panel of Bipartisan Medicare Experts Says...Medicare Needs to Be Improved to Better Serve Beneficiaries with Chronic Conditions
• Society of Critical Care Medicine: Educational Program Significantly Reduces Medical Errors January 31, 2003
• Center for Studying Health System Change: Many Physicians View Treatment Guidelines Positively January 30, 2003
  • press release
• National Quality Forum: NQF Endorses New Hospital Care National Performance Measures And A Comprehensive Framework For Hospital Care Performance Evaluation January 30, 2003
• National Quality Forum: Performance Measures And A Comprehensive Framework For Hospital Care Performance Evaluation January 30, 2003
• National Quality Forum Endorses Healthcare Safety Practices NQF Achieves Consensus on List of 26 Practices to Reduce Adverse Events January 30, 2003
• Society of Critical Care Medicine: Error Reporting Is a Reality And a Benefit To Patient Safety - ICUSRS Participants Relate Their Findings January 29, 2003
• AHRQ: Priority Areas for National Action Transforming Health Care Quality January 28, 2003
• NY Times: Sifting Through the Online Medical Jumble January 28, 2003
• AMNews: Embrace technology to stop prescription mistakes January 27, 2003
• Boston Globe: Bill would monitor doctors' behavior January 26, 2003
• Federal Register: Medicare and Medicaid Programs; Hospital Conditions of Participation: Quality Assessment and Performance Improvement (CMS)  January 24, 2003
  • CMS Press Release
• NY Times: Large H.M.O. to Make Treatment Guidelines Public  January 24, 2003
• ISMP: Water, water, everywhere, but please don't give IV  January 23, 2003
• FDA Medwatch: Serevent (salmeterol xinafoate)   January 23, 2003
• JCAHO Sentinel Event Alert: Infection control related sentinel events   January 22, 2003
  • Press Release: JCAHO Issues National Alert About Infection Control Deaths, Encourages Greater Reporting
  • Chicago Tribune: Hospital regulator targets infections
  • JCAHO Taps Expert Panel to Strengthen Infection Control Standards
• JAMA: External Incentives, Information Technology, and Organized Processes to Improve Health Care Quality for Patients With Chronic Diseases  January 22, 2003
• Health Affairs: Confronting The Barriers to Chronic Care Management In Medicare January 22, 2003
• HHS: Budget Proposal to Include $100 Million Increase to Prevent Diabetes, Obesity and Asthma Across the Country January 22, 2003
  • Washington Post: Bush Seeks Funds for Wider Effort to Curb Chronic Disease
  • NY Times: Emphasize Disease Prevention, Health Secretary Tells Insurers   
• USP: USP Issues Recommendations for Preventing Medication Errors in Children  January 21, 2003
• Annals of Internal Medicine: Risk Factors and Treatment in Women with Coronary Artery Disease  January 21, 2003
  • AP: Women Seen Undertreated for Heart Disease 
• NY Times: Gains on Heart Disease Leave More Survivors, and Questions  January 19, 2003
• Minneapolis Mistaken Mastectomy story January 19, 2003
  • Star Tribune: Lab's mistake haunts woman as she talks about her loss
  • Pioneer Press: Breasts removed in error
  • Star Tribune: Hospital official apologizes for mistaken mastectomy 
• Transferability of principles of evidence based medicine to improve educational quality: systematic review and case study of an online course in primary health care January 18, 2003
• FDA Medwatch: Ancom Anti-Hypertensive Compound Tablets January 17, 2003
• MEDPAC Hearings: Using incentives to improve the quality of beneficiary care  January 16, 2003
  • Briefing
  • Handout
  • Minutes/Transcript
• NEJM: Risk Factors for Retained Instruments and Sponges after Surgery January 16, 2003
  • NY Times: Forgotten Surgical Tools 'Uncommon but Dangerous'
  • The Star-Ledger: The surgery and the shocking souvenir 
  • USA Today: Surgeons' tools left inside 1,500 patients a year
• JAMA: Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001  January 15, 2003
  • Washington Post: U.S. Medical Care Improves Overall
  • Washington Post: Best Practices, Well Scattered
  • AHQA: JAMA Study Shows Gains Closing Quality Gap For Seniors QIO Efforts to Promote Better Clinical Practices Pay Off | Media Briefing: Closing the Quality Gap for Seniors
• JAMA: Medicare Quality Improvement Bad Apples or Bad Systems? January 15, 2003
• JAMA: Safety of Urinary Catheters   January 15, 2003
• AHRQ: Hospital-CAHPS: Web Chat Transcript   January 15, 2003
• Archives of Internal Medicine: Advice for Young Physicians   January 14, 2003
• Washington Post: Uncalculated Risks: Medical Outcome Data, if Misused, Can Deprive Patients of the Care They Need  January 14, 2003
• AHRQ: Study Finds Patients with Hip Fracture Who Leave the Hospital Too Soon Are at Risk for Worse Outcomes January 13, 2003
• CBS News: Paperless Hospitals' Popularity Grows January 13, 2003
• AMNews: Groups collaborate on hospital performance initiative January 13, 2003
• FDA MedWatch: Prempro/Premphase (conjugated estrogens/medroxyprogesterone acetate tablets)
  Premarin (conjugated estrogens tablets, USP) January 8, 2003
• State of the Commonwealth: Modernizing Health & Human Services January 8, 2003
• ISMP: Success with New Year's resolutions requires more than personal resolve  January 8, 2003
• NY Times: Frist Points to Racial Inequities in Health Care January 8, 2003
• IOM: Priority Areas for National Action: Transforming Health Care Quality January 7, 2003
  • press release
• NY Times: In an Age of Specialists, One Doctor Is Primary January 7, 2003
• Annals of Internal Medicine: A Hospitalization from Hell: A Patient's Perspective on Quality  January 7, 2003
• Annals of Internal Medicine: A Complaint against "Complaints"  January 7, 2003
• AHRQ, American Academy of Pediatrics Announce Partnership on 20 Tips to Help Prevent Medical Errors in Children January 6, 2003
  • brochure
• AMNews: Physicians, public at odds over errors January 6, 2003
• AMNews: Minority mistrust still haunts medical care January 6, 2003
• NPSF: NPSF announces solutions winner for Janssen Elder Care Award January 6, 2003
• Milwaukee Journal Sentinel: Language linked to medical mistakes January 5, 2003
• Winchester Star: Va. Not Immune to W.Va. Insurance ‘Mess’ January 4, 2003
• BMJ  January 4, 2002
  • How to evaluate and improve the quality and credibility of an outcomes database: validation and feedback study on the UK Cardiac Surgery Experience
  • Using clinical databases in practice
• Health Leaders: Six Sigma High Performance Characteristics: The Senior Leaders’ Role – Part 3 January 3, 2002
• Richmond.com: A Grim Outlook, By 2020, Virginia's hospitals will be short 20,000 nurses January 3, 2003
• AHRQ Fact Sheet: Impact of Working Conditions on Patient Safety   January 3, 2003
• Pediatrics: Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters  January 1, 2003

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