A safe practice standard for barcode technology.

Objective: Safety advocates have identified barcode verification technology as an important tool to improve health-care practices.

Methods: We evaluated the evidence for the role of barcode technology in improving a wide range of medication safety outcomes across a broad range of settings. Important implementation issues were highlighted to guide standards for the safe adoption of barcode technology.

Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action…but where will we arrive?

Radiation awareness and protection of patients have been the fundamental responsibilities in diagnostic imaging since the discovery of x-rays late in 1895 and the first reports of radiation injury in 1896. In the ensuing years, there have been significant advancements in equipment that uses either x-rays to form images, such as fluoroscopy or computed tomography (CT), or the types of radiation emitted during nuclear imaging procedures (e.g.

Safe use of electronic health records and health information technology systems: trust but verify.

Objectives: We will provide a context to health information technology systems (HIT) safety hazards discussions, describe how electronic health record-computer prescriber order entry (EHR-CPOE) simulation has already identified unrecognized hazards in HIT on a national scale, helping make EHR-CPOE systems safer, and we make the case for all stakeholders to leverage proven methods and teams in HIT performance verification.

Methods: A national poll of safety, quality improvement, and health-care administrative leaders identified health information technology safety as the hazard of greatest concern for 2013. Quality, HIT, and safety leaders are very concerned about technology performance risks as addressed in the Health Information Technology and Patient Safety report of the Institute of Medicine; and these are being addressed by the Office of the National Coordinator of HIT of the U.

Trends in computed tomography utilization rates: a longitudinal practice-based study.

Objectives: Computed tomography (CT) use has increased dramatically over the past 2 decades, leading to increased radiation exposure at the population level. We assessed trends in CT use in a primary care (PC) population from 2000 to 2010.

Methods: Trends in CT use from 2000 to 2010 were assessed in an integrated, multi-specialty group practice.

Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.

Importance: Health care-associated infections (HAIs) account for a large proportion of the harms caused by health care and are associated with high costs. Better evaluation of the costs of these infections could help providers and payers to justify investing in prevention.

Objective: To estimate costs associated with the most significant and targetable HAIs.

The cost of harm and savings through safety: using simulated patients for leadership decision support.

Objectives: The ultimate objective of this program is to provide an approach to understanding and communicating health-care harm and cost to compel health-care provider leadership teams to vote "yes" to investments in patient safety initiatives, with the confidence that clinical, financial, and operational performance will be improved by such programs.

Methods: Through a coordinated combination of literature evaluations, careful mapping of high impact scenarios using simulated patients and consensus review of clinical, operational, and financial factors, we confirmed value in such approaches to decision support information for hospital leadership teams to invest in patient safety projects.

Results: The study resulted in the following preliminary findings: ·Communication between hospital quality and finance departments can be much improved by direct collaborative relationships through regular meetings to help both clarify direct costs, indirect costs, and the savings of waste and harm to patients by avoidance of infections.

An NTSB for health care: learning from innovation: debate and innovate or capitulate.

Introduction: Economic and medical risks threaten the national security of America. The spiraling costs of United States' avoidable healthcare harm and waste far exceed those of any other nation. This 2-part paper, written by a group of aviators, is a national call to action to adopt readily available and transferable safety innovations we have already paid for that have made the airline industry one of the safest in the world.

Patient and family involvement in contemporary health care.

Objective: The objective of this article was to provide a guide to health care providers on patient and family involvement in health care.

Methods: This article evaluated the latest published studies for patient and family involvement and reexamined the objectives, the requirements for achieving these objectives, and the evidence of how to involve patients and families.

Results: Critical components for patient safety include changing the organizational culture; including patients and families on teams; listening to patients and families; incorporating their input into leadership structures and systems; providing full detail about treatment, procedures, and medication adverse effects; involving them on patient safety and performance improvement committees; and disclosing medical errors.

A new leadership role for pharmacists: a prescription for change.

Objective: Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharmacists can take to create a visible and sustainable safe medication management structure and system in the health care environment.

Methods: An evidence-based literature search was performed to determine what actions successful pharmacist leaders have taken to improve patient safety.

Leading in crisis: lessons for safety leaders.

Objective: The National Quality Forum (NQF) Safe Practices are a group of 34 evidence-based Safe Practices that should be universally used to reduce the risk of harm to patients. Four of these practices specifically address leadership. A recently published book, 7 Lessons for Leading in Crisis, offers practical advice on how to lead in crisis.

Meaningful use of computerized prescriber order entry.

Objective: It is the objective of this article to provide a guide to health care providers adopting computerized prescriber order entry (CPOE) and to explain recent developments of important concepts and initiatives such as "meaningful use" that will have significant impact on successful implementation of CPOE. The specific goals are to discuss key concepts relating to the NEW ARRA/HITECH-EHR meaningful use criteria and its relevance to CPOE Safe Practice and medication safety, summarize and update the recent scientific evidence evaluating CPOE, present the new 2010 CPOE safe practice, and suggest ways the CPOE safe practice may be expanded and harmonized with the new EHR meaningful use criteria.

Methods: This article evaluates the latest published studies in the field of CPOE and reexamines the objectives, the requirements for achieving these objectives, and evidence of efficacy for this practice.

Story power: the secret weapon.

Objective: The objective is to introduce story power as an untapped vehicle to inform, equip, and challenge leaders to drive change that can save lives, save money, and build value in communities through adoption of the National Quality Forum Safe Practices.

Method: A review of storytelling best practices from industry complemented findings from a direct survey of hospital safety leaders who presented a video story to hospital personnel. The video captured the story of death of a child from failed communication and teamwork.

Chasing zero: can reality meet the rhetoric?

Objectives: Leaders from healthcare quality, purchasing, and certifying sectors convened at a national leadership meeting held September 8-9, 2008 in Washington, DC to address issues of Hospital-Acquired Infections (HAIs). This paper provides opinion interviews from leaders who spoke at a session entitled "The Quality Choir: A Call to Action For Hospital Executives" on whether zero HAIs should be the goal of our Hospitals.

Methods: The successes of many hospitals in dramatically reducing their infection rates were examined toward goals of "Chasing Zero" infections.

The chasing zero department: making idealized design a reality.

Objectives: Leaders representing healthcare quality, purchasing, and certifying sectors convened at a national leadership meeting to address the issue of Healthcare-Associated Infections (HAIs). A session entitled "The Quality Choir: A Call to Action For Hospital Executives" featured harmonization partner organizations for the National Quality Forum Safe Practices (SPs) for Better Healthcare-2009 Update. (NQF SPs) The objective of the meeting was to determine if zero HAIs should be the improvement target for hospitals and what a Chasing Zero Department (CZD) should be like.

Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability.

Background: Disparate health care provider attitudes about autonomy, teamwork, and administrative operations have added to the complexity of health care delivery and are a central factor in medicine's unacceptably high rate of errors. Other industries have improved their reliability by applying innovative concepts to interpersonal relationships and administrative hierarchical structures (Chandler 1962). In the last 10 years the science of patient safety has become more sophisticated, with practical concepts identified and tested to improve the safety and reliability of care.