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.

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.

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.

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.

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.