Index

To view the Perspectives on Patient Safety cumulative index for 2001–2005, scroll down or click on the appropriate letter. To print this page, click on the "Print This Page" link in the upper right-hand corner.

Index references should be interpreted in the following manner: "Dec 2001, 10" means page 10 of the December issue of Perspectives on Patient Safety for the year 2001.

Abbreviations, Jan 2004, 10-11; Feb 2004, 11; Apr 2004, 8; Sep. 2004, 5-6; Aug 2005, 4-7

dangerous abbreviations list, Sep. 2004, 6; Aug 2005, 8

do-not-use list, Jan 2004, 10-11; Apr 2005, 4

and medication errors, Jan 2002, 11; Jan 2003, 6, 7; Sept 2003, 6

Compliance suggestions, Sep 2003, 6; Aug 2005, 8

JCAHO regulations, Sep 2003, 6

Standardizing, Jun 2003, 1-2

standardized abbreviations, Jan 2004, 10; Feb 2004, 11; Apr 2004, 8; Sep. 2004, 5; Aug 2005, 8

Accountability, Apr 2004, 11

for patients, Apr 2004, 11

Accreditation, May 2004, 3, 8

changes in, May 2004, 3, 8

Accreditation Issues for Risk Managers, Feb 2004, 5-6

Accreditation participation requirements, Nov 2002, 2

Accreditation process

National Quality Forum (NQF) safe practices, Nov 2004, 3, 10

Periodic Performance Review (PPR), Feb 2005, 3

Accreditation process improvement (API) initiative, Aug 2001, 7; Oct 2002, 1

see also Sentinel Event Alert, Aug 2001, 3-4, 7, 10

Accreditation Process Link, Nov 2003, 3; Feb 2004, 3, 10; May 2004, 3, 8

accreditation changes regarding safety, May 2004, 3, 8

random unannounced survey topics, Nov 2003, 3

system tracers, Feb 2004, 3, 10

Accreditation survey

agenda changes, Oct 2002, 3

compliance with National Patient Safety Goals, Nov 2004, 7–8

nurses' role in, Feb 2002, 2

patient safety, Dec 2004, 3–4

preparation questions, Dec 2001, 2, 3, 5

preparation, Jun 2002, 2

priority focus process, Oct 2002, 3

process, Jun 2001, 2; Dec 2001, 1, 3; Oct 2002, 1, 3

random unannounced, Jun 2001, 2

self-assessment process, Oct 2002, 1, 3

Standards Review Task Force, Oct 2002, 3, 9

triennial survey, Jun 2001, 2

unannounced for-cause, Jun 2001, 2

unscheduled for-cause, Jun 2001, 2

visits to patient care settings, Dec 2001, 2, 5

Active communication, Jan 2003, 4

Adolescent populations, Jan 2004, 1-2

Advanced practice registered nurses (APRNs), Jan 2004, 7-8

Adverse drug events, Jul 2001, 6; Feb 2004, 9-10; Aug 2004, 1-2, 4; May 2005, 1-3

prevention with electronic medical records, Jul 2005 1-2, 6, 8, 11

Adverse events prevention, May 2001, 3

accreditation survey process for, Jun 2001, 2

communication with individuals and families, Jul 2001, 10

drug shortages, Mar 2005, 3-4

learning from near misses, Oct 2001, 4-5

near miss reporting program, Oct 2001, 8-9

and performance improvement, Jun 2001, 7

program for, May 2001, 3

and staffing effectiveness, Sep 2001, 4-5

Adverse medical events

emotional support, May 2005, 6

Adverse pediatric events, Nov 2004, 1–2, 4

Agency for Healthcare Research and Quality (AHRQ), Apr 2005, 3

20 Tips to Help Prevent Medical Errors in Children, Nov 2004, 4

evaluating employees' attitudes, Mar 2005, 5–7

Guest Commentary, Nov 2001, 6

Quick Tips, Oct 2002, 10

research on pediatric adverse events, Nov 2004, 1

Survey User's Guide, Mar 2005, 6

Agency screening, Jul 2004, 5

Aggressive behavior, Mar 2004, 5

Alarm systems, see also Clinical alarm system, Jan 2003, 10-11; Sep 2003, 10; Sep. 2004, 8-9; Aug 2005, 9

biomedical PM program, Apr 2003, 8

compliance suggestions, Sep 2003, 10; Sep. 2004, 9; Aug 2005, 9

compliance tip, Jan 2003, 11

improving effectiveness of, Sep. 2004, 8-9; Aug 2005, 9

JCAHO requirements, Jan 2003, 10; Sep 2003, 5; Sep. 2004, 9; Aug 2005, 9

patient safety indicators, Dec 2003, 5-6

review of, Jan 2003, 10-11; Sep. 2004, 8-9; Aug 2005, 9

Allergies, Jul 2004, 7-8

latex, Jul 2004, 7-8

notification, Jan 2005, 7–8

Alternate Family Care, Inc. (AFC)

case study, Jun 2002, 8-9

overcoming barriers, Jun 2002, 9

tracking techniques, Jun 2002, 8-9

use of measureable outcomes, Jun 2002, 8

Alternative care sites, Apr 2005, 6

Ambulatory Care Patient Safety Standards, Apr 2003, 1, 2, 4; Dec 2004, 3-4; Feb 2005, 7

Ambulatory care, see also outpatient facilities, Mar 2003, 5-6,8; Apr 2004, 4-5

and 2004 National Patient Safety Goals, Apr 2004, 4-5

clinical alarm systems, Feb 2005, 7

competence assessment, Nov 2002, 2

critical tests and results, Apr 2005, 11

fire prevention, Feb 2005, 6

LIP credentialing and privileging, Nov 2002, 1

Life Safety Code compliance, Feb 2005, 7

medication use, Nov 2002, 3

National Patient Safety Goals, Feb 2005, 7

performance improvement, Nov 2002, 1, 3

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, Feb 2005, 9–10

American Association of Nurse Anesthetists

Web site, Oct 2002, 10

American Hospital Association

measuring organizational conditions, Mar 2005, 5

American Medical Association

informed consent guidelines, Mar 2005, 1

American Society of Health System Pharmacists (ASHP)

Drug Shortages Bulletin, Mar 2005, 4

survey on drug shortages, Mar 2005, 3

Anesthesia,Mar 2005, 3

Anesthesia awareness, Jan 2005, 11

Anesthesia induction, Feb 2005, 5–6

Anesthesia safety, Mar 2004, 11

Annenberg Conference on Patient Safety, Apr 2005, 8

Apologies, Apr 2005, 7–8

Appalachian Behavioral Healthcare (ABH)

case study, Jan 2002, 8-9

action plan, Jan 2002, 8-9

staff education, Jan 2002, 8-9

use of performance measurement data, Jan 2002, 8-9

Artificial fingernails, Nov 2003, 10

Aspergillosis, Aug 2004, 7-8

prevention guidelines, Aug 2004, 7-8

Assessment, May 2004, 5-6; Jun 2004, 5-6

data collection, May 2004, 6

depth of, May 2004, 6

and elopement risk, Jun 2004, 5-6

and restraint and seclusion, May 2004, 5-6

standards, May 2004, 5

timeliness of, May 2004, 5-6

Assessment and care services, Dec 2003, 1-2

Assessment and reassessment, Jan 2004, 3-4

improving of, Jan 2004, 3-4

Assessment of patients

checklist, Nov 2001, 5

and error prevention, Nov 2001, 4-5

and RUS topics, Apr 2003, 3, 6

Assessments, initial

for behavioral health, Nov, 2002, 3

in emergency departments, Dec 2002, 1, 3

for hospitals, Nov 2002, 3, 6

for long term care, Nov 2002, 6

proper assessment, Dec 2002, 2

Association for Professionals in Infection Control and Epidemiology (APIC), Apr 2003, 11; May 2005, 4

Association of Perioperative Registered Nurses (AORN), Feb 2005, 10

Automated dispensing systems, Aug 2003, 3-4

managing overrides, Aug 2003, 3-4

Awards

John M. Eisenberg Patient Safety Award, Aug 2002, 6; June 2003, 8

Backup suppliers, Apr 2005, 6

Bar codes, Aug 2004, 9-10; Apr 2005; 1–2, 10

implementation of, Aug 2004, 9-10

measuring effectiveness of, Aug 2004, 10

and preventing medication error, Aug 2004, 9-10

Behavioral health care

and 2004 National Patient Safety Goals, Apr 2004, 5

and 2005 National Patient Safety Goals, Dec 2004, 3-4

competence assessment, Nov 2002, 3

critical tests and results, Apr 2005, 11

discharge planning, Nov 2002, 3

initial assessment, Nov 2002, 3

Life Safety Code compliance, Feb 2005, 7

medication use, Nov 2002, 3

safety standards, May 2002, 1, 3, 9

special procedures, Nov 2002, 3

standards applicability matrix, May 2002, 3

Bench tests

human factors engineering strategies, Jan 2005, 4

Benchmarking, Mar 2002, 7

patient safety, Dec 2004, 2, 8

Berkshire Medical Center, Apr 2005, 1

Best practices

patient safety, Feb 2005, 3

Bioterrorism

preparedness, May 2005, 4

Bipolar disorder

suicide prevention, Feb 2005, 4

Blame-free culture, Oct 2003, 6; Feb 2004, 9

Blameless reporting, Apr 2003, 6

Blood transfusions and patient safety, Oct 2001, 10; Mar 2002, 5

errors, Jan 2004, 5-6

process improvements, Nov 2001, 3

reduction of errors, Dec 2002, 11

tips for, Oct 2001, 10

Bloodstream infection rates, Jan 2004, 9-10

reduction of, Jan 2004, 9, 11

Bone tissue storage, May 2002, 10

protocol for, May 2002, 10

Brainstorming

prioritizing failures, Mar 2005, 9–10

Business case for patient safety, Aug 2004, 1-2, 4

impediments to, Aug 2004, 4

quality vs. safety, Aug 2004, 2, 4

reporting of, Aug 2004, 4

Care planning, Nov 2002, 6; Jan 2004, 6; Jun 2004, 6

communication, Jan 2004, 6

improving the provision of, Jan 2004, 4

patient identification, Jan 2004, 6

patient involvement in, Aug 2005, 14

staff orientation and training, Jan 2004, 5

staffing levels, Jan 2004, 6

storage of blood, Jan 2004, 6

Care provision strategies, Oct. 2004, 8-9

and cultural competence, Oct. 2004, 8-9

Case Study

Allegheny General Hospital, Jul 2005, 9-10

Alternate Family Care, Inc (AFC), Jun 2002, 8-9

Appalachian Behavioral Healthcare (ABH), Jan 2002, 8-9

Barnes-Jewish Hospital, Jan 2004, 9, 11

Catholic Health East, Oct 2003, 9-10

Chapel Hill Community (CHC), Jul 2002, 8-9

Concord Collaborative Care Model, Aug 2002, 8–9, 11

Denver Community Health Service, Jul 2001, 8-9

Fisher-Titus Medical Center, Aug 2003, 8, 10

Fostoria Community Hospital, May 2005, 9-10

Good Samaritan's patient safety and satisfaction, Dec 2004, 9–10

Gottlieb Memorial Hospital, Nov 2001, 8-9

Hazelden Foundation, Feb 2004, 9-10

Hines VA Hospital, May 2004, 9-10

Hospital for Special Surgery (HSS), May 2002, 8-9

Huger Mercy Living Center, Jul 2004, 9-10

Ingham Regional Medical Center (Lansing, Michigan), Apr 2005, 9–10

Kaiser Permanente, Apr 2002, 8-9

Kaleida Health, Oct 2002, 8-9

Lake Grove at Maple Valley (LGMV), Jun 2001, 8-9

MacLeod Health, Jun 2005, 9-10

Marworth, Jun 2003, 9-10

Medical Arts Surgery Center, Nov 2003, 9-10

Methodist Hospital of Southern California, Mar 2004, 9-10

Missouri Baptist Medical Center (MBMC), Nov 2002, 8–9

North Broward Medical Center, Jun 2004, 9-10

North Colorado Medical Center (NCMC), Feb 2005, 9-10

Northeast Methodist Hospital, Dec 2001, 8-9

Ohio Hospital Association (OHA), Nov 2004, 9-10

Patient Safety Center of Inquiry (PSCI), May 2001, 8-9

Philadelphia Protestant Home, Oct. 2004, 5-6, 10

Quaboag Valley Visiting Nurse Association, Mar 2005, 9–10

Rancho Los Amigos National Rehabilitation Center, Feb 2002, 8-9

Roncalli Health Care Management, Sep 2001, 8-9

SEM Haven Health and Residential Care Center, Mar 2002, 8-9

South Carolina Hospital Association, Jun 2005, 9-10

SSM Health Care (SSMHC), Oct 2001, 8-9

St Joseph Hospital West, Oct 2001, 8-9

Sutter Amador Hospital, Aug 2004, 9-10

Twin Valley Behavioral Healthcare, Sep 2002, 8-9

University of Pittsburgh Medical Center (UPMC), Jan 2005, 9-10

VA Medical Center, Dec 2002, 8-9

William S. Middleton Memorial VA Medical Center, Jul 2003, 7-8, 10

Catholic Health East, Oct 2003, 9-10

Centers for Disease Control and Prevention (CDC), Dec 2004, 4

Clinical Registry for Terrorism and Emergency Response Updates and Training Opportunities, May 2005, 4

tracking drug shortages, Mar 2005, 4

Centers for Medicare and Medicaid Services (CMS), Jun 2002, 1; Dec 2004, 4

Conditions of Participation (CoPs), Mar 2005, 1

Central line bloodstream infections, Apr 2005, 10

Central Line Infections

prevention, May 2005, 1-3

Chain-of-command policies, Jan 2005, 5–6

Chapel Hill Community (CHC)

case study, Jul 2002 8–9

education of staff and residents, Jul 2002, 9

fall reduction program, Jul 2002, 8–9

Chart review, Dec 2004, 1

Checklist

VA Ann Arbor Healthcare System (VAAAHS), Mar 2003, 9–10

Chemotherapy orders, Nov 2004, 4

Children's Hospitals and Clinics, May 2003, 1-2

Clinical alarm system, Jan 2003, 10-11; Dec 2003, 8; Apr 2004, 4-6; Jun 2004, 9-10; Feb 2005, 7

compliance tip, Jan 2003, 11

ensuring that alarms can be heard, Jun 2004, 9-10

improving effectiveness of, Apr 2004, 4-6; Jun 2004, 9-10

improving response time, Jun 2004, 10

JCAHO requirements, Jan 2003, 10

measuring effectiveness of, Jun 2004, 10

review of, Jan 2003, 10-11

setting alarms appropriately, Jun 2004, 9

testing of, Jun 2004, 9

Clinical laboratories and patient safety, Oct 2001, 10

Clinical practice guidelines (CPGs), May 2001, 10

and error prevention, May 2001, 10

Clinical surveillance, Dec 2004, 1-2

Clinical/service (C/S) outcome indicators, Aug 2001, 6

Clinical/service groups, Apr 2004, 1-2, 6

Cognitive walk through

human factors engineering strategies, Jan 2005, 4

Cognitively impaired populations, Jan 2004, 2, 4

Collaboration with patients, May 2003, 1-2, 4

College of American Pathologists (CAP), Apr 2005, 1

Comlaint monitoring, Jun 2005, 3

Commonwealth Fund, the,Mar 2005, 2

Communication

abbreviation usage, Jan 2003, 6, 7

and 2004 National Patient Safety Goals, Apr 2004, 4, 6

and computerized prescriber order entry (CPOE), Sep 2002, 5

and cultural competence, Feb 2002, 10

and error reduction, Jun 2001, 4-5

and infant abductions, Oct 2003, 8

and laboratories, Jul 2004, 4

compliance tip, Jan 2003, 5

education, Apr 2004, 8

improving the effectiveness of, Apr 2004, 4, 6, 7

JCAHO requirements, Jan 2003, 4, 6

strategy suggestions, Jan 2003, 4, 6; Apr 2004, 7-8

and medication-related sentinel events, Jun 2001, 4

and operative and postoperative complications prevention, Jun 2001, 5

and outcomes of care, Jul 2001, 10

and safety program, Sep 2001, 1, 3

and suicide prevention, Jun 2001, 5

and verbal orders, Sep 2002, 4; Jan 2003, 4-5; Aug 2005, 4-5

and wrong-site surgery prevention, Jun 2001, 5

challenges in pediatric care, Nov 2004, 2

effectiveness, Jan 2003, 4-6; Feb 2005, 1-2

epidemics, Feb 2004, 2

guidelines, Dec 2004, 3

identification of barriers, Sep 2002, 4-5

improving hand-off communication, Jul 2005, 11

ineffective, Feb 2005, 1–2

multifaceted, Feb 2005, 3

overcoming barriers to, Sep 2002, 4-5

patient complaints and suggestions, Dec 2004, 2

physician-to-physician communication strategies, Nov 2004, 11

purposeful, Feb 2005, 8

SBAR technique, Feb 2005, 2, 8

staff-to-physician communication strategies, Nov 2004, 11

strategies, Nov 2004, 11

with patients and families, Sep 2001, 6; Apr 2004, 8; Aug 2005, 14

Communication effectiveness, Sep 2003, 5-6; Dec 2003, 2, 7; Sep 2004, 4-6; Aug 2005, 4-7

compliance suggestions, Sep 2003, 5-6; Sep 2004, 4-5; Aug 2005, 6-7

Joint Commission requirements, Sep 2003, 5; Sep 2004, 4-6; Aug 2005, 4-7

Communication Priority Focus Area, Apr 2004, 7-8

scope and goal of, Apr 2004, 7

Communication strategies, Mar 2004, 6; Oct. 2004, 8

and cultural competence, Oct. 2004, 8

Competence assessment, May 2002, 5; Nov 2002, 3, 4-5, 10

and utilities management strategies, Dec 2004, 6,8

Competence challenges in pediatric care, Nov 2004, 4

Complaint data, Aug 2001, 7

Complementary alternative medicine (CAM), Jan 2002, 2

Compliance data results, Jul 2003, 3-4, 10

Compliance tips, May 2001, 3, 5; Oct 2001, 3, 5; Mar 2002, 2

Component and practitioner site implementation, Sep 2004, 14-15; Aug 2005, 15

Comprehensive Accreditation Manual for Hospitals (CAMH), , May 2001, 1; Aug 2001, 6

environment of care intent statement revisions, Aug 2001, 6

leadership standards changes, May 2001, 1, 3

performance improvement standards revisions, May 2001, 3

staffing effectiveness standards, Aug 2001, 6

use of safety standards, May 2001, 1

Computerized physician order entry (CPOE)

eliminating problems, Apr 2003, 7

preventing medication errors, May 2003, 3-4

reducing risk of adverse pediatric events, Nov 2004, 3-4

Computerized prescriber order entry, Feb 2004, 5-6

alternatives to, Feb 2004, 5-6

Concord Collaborative Care Model

case study, Aug 2002, 8–9

barriers, Aug 2002, 11

benefits, Aug 2002, 9

development of model, Aug 2002, 8

measurement of success, Aug 2002, 9

model initiative, Aug 2002, 8

patient and family involvement, Aug 2002, 9

patient/staff conference, Aug 2002, 8–9

Conference Report

Ambulatory Care and Safety and Service to Patients, Jan 2002, 6

2001 National Conference on Quality and Safety in Health Care, Dec 2001, 6

Designing Safer Health Care Systems, Jun 2001, 6

Let’s Talk: Communicating Risk and Safety in Health Care, Sep 2001, 6

Patient Safety: Let’s Get Practical, Jul 2002, 6

A Teamwork Approach for Responding to a Sentinel Event, May 2002, 6

"We the People": The Institute for Healthcare Improvement's Forum on Quality Improvement, Mar 2002, 6

Continuity of care

and electronic medical records, Jul 2005 1-2, 6, 8, 11

Contracted staff, Jul 2004, 5-6

orientation and training requirements, Jul 2004, 5-6

Credentialing and privileging of LIPs, Nov 2002, 1, 6

Creutzfeldt-Jakob Disease (CJD), Jul 2002, 11

and communication, Jul 2002, 11

education and competence, Jul 2002, 11

information management, Jul 2002, 11

instrument/equipment use, Jul 2002, 11

patient assessment, Jul 2002, 11

Critical access hospitals

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, Feb 2005, 9–10

Critical processes, Oct 2002, 3

Critical test results, Sep 2003, 5

Criticality of failure modes, Jun 2002, 4-5

Crossing the Quality Chasm: A New Health System for the 21st Century, Jun 2001, 1, 3

Cultural competence, Feb 2002, 10; Oct. 2004, 1-2, 8-9

accreditation requirements, Oct. 2004, 2

alternative medical practices, Feb 2002, 10

and safety challenges, Oct. 2004, 1-2

care provision strategies, Oct. 2004, 8-9

communication barriers, Feb 2002, 10

communication strategies, Oct. 2004, 8

educational strategies, Oct. 2004, 9

enhancing, Oct. 2004, 2, 8-9

Joint Commission standards, Oct. 2004, 2

leadership strategies, Oct. 2004, 8

patient assessment, Oct. 2004, 8

Culturally sensitive patient assessment, Oct. 2004, 8

Culture of Patient Safety, Mar 2004, 9-10

Culture of safety, Jul 2001, 1, 3, 6; Jan 2005, 9–10; Jul 2005, 5-6

error reporting, Jul 2001, 3

leadership, Jul 2001, 1

proactive error reduction, Jul 2001, 3

sample strategies tool, Aug 2001, 5

tips for creating, Jul 2001, 3

Data collection and usage, Nov 2003, 5-6; 7-8; Feb 2004, 3

analyzing, Nov 2003, 8

for patient safety, Dec 2004, 2, 8

collection tips, Nov 2003, 7

methods, Mar 2005, 6-7

tracking results, Nov 2003, 6

Data management, Jul 2001, 2; Oct 2003, 9-10

analysis, Jul 2001, 2

and performance improvement, Jul 2001, 2

collection, Jul 2001, 2

for safety program, Sep 2001, 1; Dec 2004, 1-2

minimum data sets, Jul 2001, 2

Defining error, Jun 2003, 3-4

Demographics challenges in pediatric care, Nov 2004, 2

Denver Community Health Service

case study, Jul 2001, 8-9

clinic visits, Jul 2001, 8

continuous standards compliance, Jul 2001, 8-9

mock surveys, Jul 2001, 8

review of incident reports, Jul 2001, 8-9

Department of Defense (DoD)

Military Health System, Mar 2005, 5

Depression, Feb 2005, 4, 6

Developmental issues in pediatric care, Nov 2004, 1

Dimensions of performance, Mar 2002, 10

safety, Mar 2002, 10

Disaster preparedness, Jan 2002,1, 3, 10; May 2005, 4

external, Jan 2002, 3

internal, Jan 2002, 10

Discharge planning, Nov 2002, 3; Jan 2004, 4

improving of, Jan 2004, 4

Discipline-specific roles in safety, Apr 2003, 7, 8

Disease epidemiology in pediatric care, Nov 2004, 1–2

Disease-specific care, Feb 2005, 7

critical tests and results, Apr 2005, 11

Do-not-use list, Jan 2004, 10-11

Drug concentrations

limiting of, Jul 2003, 4

Drug shortages

alternative sources, Mar 2005, 4, 8

tracking, Mar 2005, 3–4, 8

Drug use evaluation,Mar 2005, 4

Drug-related challenges in pediatric care, Nov 2004, 2

Education

of practitioners on fluoroscopic safety, Jul 2002, 1, 3

Speak Up campaign, Jun 2002, 1

Eisenberg, John M., Patient Safety Award, Aug 2002, 6

Elderly population

monitoring prescriptions, Apr 2005, 3

Electrical/gas systems, Nov 2004, 5

Electronic health record see electronic medical records (EMRs)

Electronic medical records (EMRs), Jul 2005, 1-2, 6, 8, 11

and reducing medical erros, Jul 2005, 2, 6

Elements of performance

Leadership (LD) standard, Feb 2005, 11

Elopement, May 2004, 9-10; Jun 2004, 5-6

and risk assessment, Jun 2004, 6

and root cause analysis, May 2004, 9-10

care planning, Jun 2004, 6

cultural issues, May 2004, 9, 10

initial assessment, Jun 2004, 5

reviewing of incidents, May 2004, 9

search procedure, May 2004, 9-10

staff competence, Jun 2004, 6

staff education, May 2004, 9-10

Emergency department care, Dec 2002, 1, 3, 9; Jul 2003, 11; Jun 2004, 11

drug shortages, Mar 2005, 3

medical emergency team (MET) approach, Mar 2005, 11

overcrowding, Jun 2004, 11

patient assessment, Dec 2002, 1, 3

transfer of patient, Dec 2002, 3, 9

treatment delays, Dec 2002, 3

violence prevention, Dec 2002, 3; July 2003, 11

Emergency management, Feb 2002, 7

activities, Jan 2002, 1, 3, 10

and medical emergencies, Dec 2002, 8-9

and restraint use, Apr 2002, 10

during floods, Apr 2005, 5–6

evacuation plans, Apr 2005, 5–6

planning, Apr 2005, 5

risk management, Feb 2002, 7

staffing, transportation, and supplies, Apr 2005, 6

Emergency preparedness, Feb 2004, 1-2

Employee Assistance Programs, Oct 2003, 6

Engaging patients in patient safety, Apr 2004, 11

Entry to care, Jan 2004, 3

improving of, Jan 2004, 3

Environment of Care, Jan 2002, 4-5

overcoming root causes, Jan 2002, 4-5

restraint use, Apr 2002, 10

standards revisions, Mar 2002, 2

Environmental safety

role in patient safety, Mar 2005, 5

Epidemics, Feb 2004, 1-2, 4

communication, Feb 2004, 2

emergency preparedness, Feb 2004, 1-2

facility access during, Feb 2004, 4

flu, Feb 2004, 1

identifying, Feb 2004, 1-2, 4

infection control, Feb 2004, 4

isolating cases, Feb 2004, 3

planning for, Feb 2004, 2

staffing needs, Feb 2004, 2

supplies, Feb 2004, 2

Equipment-related issues in pediatric care, Nov 2004, 2, 4

Error causation, Nov 2001, 1, 3

Error defining, Jun 2003, 3-4

Error reduction, Mar 2002, 1, 3, 9; Jun 2002, 1,3; Aug 2002, 1, 3; Feb 2004, 6; Nov 2004, 2, 4

and resident fatigue, May 2005, 5

patient involvement, Jun 2002, 1, 3

patient safety taxonomy, Aug 2002, 1, 3

pediatric risk events, Nov 2004, 2, 4

Speak Up campaign, Jun 2002, 1, 3

and failure mode and effects analysis, May 2005, 7

Error reporting, Jul 2001, 3, 7

culture of safety, Jul 2001, 3

risk management, Jul 2001, 7

Ethical resposibilities

apologies, Apr 2005, 7–8

Evacuation plans, Apr 2005, 5–6

Event report forms, Apr 2004, 9-10

Explicit recall, Jan 2005, 11

Failure costs, Jun 2001, 7

Failure mode, effects, and criticality analysis (FMEA), Nov 2001, 1, 3; May 2002, 6; Jun 2002, 4-5; Jul 2002, 7; Aug 2002, 6; Sep 2002, 4; Oct 2002, 4-5; Dec 2002, 4-5; Mar 2003, 7-8; Apr 2003, 9-10; Aug 2003, 5-6; Mar 2004, 7-8

and high risk patient care processes, May 2005, 7

and medication management, Mar 2004, 7-8

and root cause analysis, Dec 2002, 5; Mar 2003

basics, Nov 2001, 1

benefits of, Mar 2004, 7

blood transfusion process, Nov 2001, 3

determining criticality, Jun 2002, 4-5

difficult aspects of, Dec 2002, 4–5

error causation, Nov 2001, 1, 3

identification of processes for, Dec 2002, 4

infusion pumps, Apr 2003, 9-10

integration into performance improvement program, Dec 2002, 5

multidisciplinary approach to, Jul 2002, 7

on home infusion, Mar 2005, 9-10

overcoming communication barriers, Sep 2002, 4

preliminary steps, Jun 2002, 4

processes, Aug 2002, 4

questions and answers, Oct 2002, 4-5; Dec 2002, 4-5

measurement of effectiveness, Oct 2002, 5

prioritization for, Oct 2002, 4

steps of, Mar 2004, 7-8

strategies, Mar 2004, 8

team members for, Oct 2002, 4-5

time frame of, Oct 2002, 4

tips for, Oct 2002, 5

risk priority numbers (RPN), Jun 2002, 4-5

steps for conducting, Nov 2001, 3

steps in the FMEA process, Aug 2003, 5

tools for usage, Aug 2003, 5-6

variation of approaches to, Dec 2002, 4

worksheets, Aug 2003, 6

Fall rates, Nov 2003, 5-6; Jul 2004, 9-10

collecting and using data, Nov 2003, 5-6

implementing strategies for prevention, Nov 2003, 5

Falls, Jun 2001, 11; Jun 2003, 5-6, 8; July 2003, 7-8, 10; Jul 2004, 10; Sep 2004, 11; Aug 2005, 12

assessment/prevention, Nov 2001, 5; Mar 2002, 8-9; Jul 2004, 10

case study, Mar 2002, 8-9

common causes, Jun 2001, 11

compliance suggestions, 11

educating staff about, Jun 2003, 5-6, 8

fatal, Aug 2001, 4

Joint Commission requirements, Sep. 2004, 11; Aug 2005, 12

patients at risk, Jul 2004, 9

prevention program, Jul 2003, 7-8, 10; Jul 2004, 10

prevention program: teaching/learning packet, Jan 2005, 10

prevention without restraint use, Dec 2002, 6-7

prevention, Dec 2004, 4

reduction program, Jul 2002, 8–9

risk factors, Jun 2003, 5-6; Sep. 2004, 11; Aug 2005, 12

root causes of, Jun 2003, 5-6, 8

Family

and communication of adverse events, Jul 2001, 10; Sep 2001, 6

Featured Form, Apr 2003, 9-10; Apr 2004, 9-10

and Event Report Form, Apr 2004, 9-10

Field observations

human factors engineering strategies, Jan 2005, 4

Final verification process, Sep. 2004, 3; Aug 2005, 4

Fire prevention

anesthesia induction, Feb 2005, 5–6

in home care, Nov 2004, 5-6

National Patient Safety Goals, guidelines, Dec 2004, 4

surgical fires, Feb 2005, 5–6, 7

Fire safety

drills and restraint use, Apr 2002, 10

Firearms risk management program, Sep 2002, 4

reduction of patient suicide, Sep 2002, 8-9

Float staff, Jul 2004, 5-6

orientation and training requirements, Jul 2004, 5-6

Floods, Apr 2005, 5–6

Flu, Feb 2004, 1

immunization programs, Feb 2004, 1

Fluoroscopy safety, Jul 2002, 1, 3

risks of, Jul 2002, 1, 3

Focus Groups

and medication errors, Jun 2003, 9-10

and Performance Inmprovement, Jun 2003, 9-10

Focus on Five

abbreviations, Jan 2002, 11

anesthesia safety, Mar 2004, 11

blood transfusion error reduction, Dec 2002, 6-7

Creutzfeldt-Jakob Disease (CJD), Jul 2002, 11

engaging patients in safety, Apr 2004, 11

falls, Jun 2001, 11

fire safety and home care, Sep 2001, 11

high-alert medications, May 2001, 11

injectable potassium chloride concentrate, May 2001, 11

insulin, May 2001, 11

intravenous anticoagulants, May 2001, 11

opiates and narcotics, May 2001, 11

high-risk suicide groups, Jul 2001, 11

improving hand-off communication, Jul 2005, 11

infant abduction prevention, Apr 2002, 11

infection control in medication storage bins, Jun 2005, 11

infusion pump use safety, Nov 2002, 11

kernicterus prevention, Nov 2001, 11

medical gas use, May 2002, 11

medication errors, Sep 2002, 11

improper does/quantity, Sep 2002, 11

omission errors, Sep 2002, 11

prescribing error, Sep 2002, 11

protecting patients and staff from violence, Nov 2003, 11

wrong time, Sep 2002, 11

National Patient Safety Goal 7b, Aug 2004, 11

National Patient Safety Goal 11A, Oct. 2004, 11

preventing violence in emergency departments, Jul 2003, 11

sodium chloride solutions, May 2001, 11

nosocomial infections, Apr 2003, 11

obese patients, Jul 2004, 11

operative and postoperative complications, Mar 2003, 11

patient identification, Dec 2003, 11

pediatric medication errors, Feb 2004, 11

prevention of, Feb 2004, 11

restraint-related deaths, Feb 2002, 11

equipment-related factors, Feb 2002, 11

inadequate care planning, Feb 2002, 11

incomplete assessments, Feb 2002, 11

insufficiency of staff, Feb 2002, 11

lack of adequate observation procedures, Feb 2002, 11

lethal means assessment, Aug 2001, 11

National Strategy for Suicide Prevention: Goals and Objectives for Action (NSSP), Aug 2001, 11

needlestick prevention program, Dec 2001, 11

risk reduction strategies, Nov 2001, 11

suicide screening, Aug 2001, 11

support, Aug 2001, 11

training implementation, Aug 2001, 11

risk factors that contribute to surgical tools being left in patients, Jun 2003, 11

suicide risk reduction and prevention, Aug 2001, 11

surgical fires, Oct 2003, 11; Oct. 2004, 11

surgical site infections, Oct 2001, 11

antimicrobial prophylaxis, Oct 2001, 11

asepsis and surgical technique, Oct 2001, 11

postoperative incision care, Oct 2001, 11

preoperative preparation of the patient, Oct 2001, 11

surveillance, Oct 2001, 11

treatment delays, Oct 2002, 11

communication breakdowns, Oct 2002, 11

continuum of care issues, Oct 2002, 11

inadequate patient assessment, Oct 2002, 11

inadequate staffing, Oct 2002, 11

lack of critical patient information, Oct 2002, 11

ventilator-related adverse events; Jun 2002, 11

wrong site surgery, Mar 2002, 11

causes of, Mar 2002, 11

risk reduction strategies, Mar 2002, 11

Food and Drug Administration (FDA)

bar codes, Apr 2005, 2

FDA rules, Jun 2003, 7

tracking drug shortages, Mar 2005, 4

Functional needs assessment

human factors engineering strategies, Jan 2005, 4

Geneva University Hospitals (Switzerland), Apr 2005, 1

Georgetown University Hospital (Washington, DC)

patient identification, Apr 2005, 2

Geriatric populations, Jan 2004, 2

physical limitations of, Jan 2004, 2

Gottlieb Memorial Hospital,Mar 2005, 4

case study, Nov 2001, 8-9

ER issues, Nov 2001, 9

laboratory specimens, Nov 2001, 8-9

Group purchasing organizations

Guest Commentary

Agency for Healthcare Research and Quality (AHRQ), Nov 2001, 6

business case for patient safety, May 2001, 6, 9

To Err is Human: Building a Safer Health System, Nov 2001, 6

Leapfrog Group values, Feb 2002, 6, 9

medication safety improvement, Jul 2001, 6

patient safety

definitions, Apr 2002, 6

goals, Apr 2002, 6

practices, Nov 2001, 6

risk management role, Jun 2002, 6

Guideline for Infection Control in Health Care Personnel, May 2005, 4

Hand hygiene, Mar 2003, 1–2; Sep 2003, 10-11; Oct. 2004, 3-4; Apr 2005, 9

educating patients about, Oct. 2004, 10

glove usage, Oct. 2004, 4, 10

guidelines for, Mar 2003, 1

importance of, Apr 2003, 11

nail care, Oct. 2004, 4

skin care, Oct. 2004, 4

Hand washing, Sep 2002, 2

"Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury", Apr 2005, 3

Health care costs, Aug 2004, 1-2, 4

and health care-associated infections, Jun 2005, 1-2, 4

Health care inflation, Jun 2005, 1-2, 4

Health care organizations

alternative care sites, Apr 2005, 6

critical tests and results, Apr 2005, 11

ethical responsibilities, Apr 2005, 7–8

implementing NQF's Safe Practice 10, Mar 2005, 2

measuring organizational conditions, Mar 2005, 5

monitoring prescriptions, Apr 2005, 3

Health care–associated infections, Sep 2003, 10-11; Dec 2003, 8; Apr 2004, 5-6; Jun 2004, 7; Aug 2004, 7-8; Sep. 2004, 9-10; Aug 2005, 12-13

and patient isolation, Jun 2004, 7-8

aspergillosis, Aug 2004, 7-8

CDC statistics on, Jun 2005, 2

compliance suggestions, Sep 2003, 11

guideline format, Aug 2004, 8

and increased health care cost, Jun 2005, 1-2, 4

Joint Commission requirements, Sep 2003, 10-11; Sep. 2004, 9; Aug 2005, 12-13

Legionnaires disease, Aug 2004, 7

pneumonia, Aug 2004, 7-8

methicillin-resistant Staphylococcus Areus (MRSA), Jul 2005, 10

prevention guidelines, Aug 2004, 7-8

implementation strategies, Aug 2004, 8

reducing risk of, Apr 2004, 4-6; Sep. 2004, 9-10; Jul 2005, 9-10; Aug 2005, 12-13

respiratory infections, Aug 2004, 7-8

respiratory syncytial virus (RSV), Aug 2004, 8

Health Industry Group Purchasing Association

Pharmacy Working Group, Mar2005, 4, 8

Health Insurance Portability and Accountability Act of 1996 (HIPAA), Jul 2002, 5

Health literacy

definition, Mar 2005, 1

staff education, Mar 2005, 8

Herbal medicines, Jan 2002, 2; Jan 2005, 8

surgery interference, Jan 2002, 2

Heuristic evaluation

human factors engineering strategies, Jan 2005, 4

HFE. See Human factors engineering

High alert medications, Aug 2001, 3; Jan 2003, 6-8; Sep 2003, 6-7; Dec 2003, 7-8; Apr 2004, 4-6

common risk factors, Jan 2003, 8

compliance suggestions, Sep 2003, 7

improving safety of, Apr 2004, 4-6

JCAHO requirements, Jan 2003, 6-7; Sep 2003, 10-11

proactive planning tips, Jan 2003, 8

sample alternative, Sep 2003, 7

High-severity prescriptions, Apr 2005, 3

Home care

critical tests and results, Apr 2005, 11

and fire safety, Sep 2001, 11; Nov 2004, 5-6

and medication errors, Aug 2004, 5-6

and National Patient Safety Goals, Feb 2004, 8; Dec 2004, 4

safety assessment, Nov 2004, 5-6

Home Care Safety Standards, Aug 2003, 1-2

proactive approach, Aug 2003, 1-2

Home infusion,safety improvments, Mar 2005, 9-10

Hopelessness, Feb 2005, 4, 6

Hospital for Special Surgery (HSS)

case study, May 2002, 8-9

improvement process, May 2002, 9

interdisciplinary team, May 2002, 8-9

medication variance reduction, May 2002, 8-9

Hospitals

chain-of-command policies, Jan 2005, 5–6

clinical alarm systems, Feb 2005, 7

compliance with National Patient Safety Goals, Nov 2004, 7-8

critical tests and results, Apr 2005, 11

EC planning, Nov 2002, 3

initial assessment, Nov 2002, 3, 6

Life Safety Code compliance, Feb 2005, 7

medication use, Nov 2002, 6

orientation and training of staff, Nov 2002, 6

patient flow strategies, Feb 2005, 11

pediatric adverse events, Nov 2004, 1-2, 4

Periodic Performance Review (PPR) requirements, Feb 2005, 3

preventing wrong site surgery, Nov 2004, 9-10

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, Feb 2005, 9–10

verbal orders, Nov 2002, 6

Hotline, Office of Quality Monitoring (OQM), Aug 2001, 7

Human factors engineering

equipment analysis, Jan 2005, 4

root cause analysis, Jan 2005, 1–2, 4

Human Resources (HR)

screening indicators, Aug 2001, 6

standards, May 2001, 2, 3; Sep 2001, 4; Oct 2001, 1, 3

Hurricanes, Apr 2005, 5–6

Identification bands, Apr 2005, 1–2, 10

Immunization programs, Feb 2004, 1

Implicit recall, Jan 2005, 11

Improving communication, Aug 2003, 8, 10

Fisher-Titus Medical Center, Aug 2003, 8, 10

Improving organization performance, Jul 2001, 2; Sep 2001, 4; Nov 2002, 1, 3

Improving patient identification, Jul 2003, 4

Incident reports, Oct 2001, 7

challenges to using, Oct 2001, 7

Indicators, Aug 2001, 6

clinical/service (C/S) outcome, Aug 2001, 6

screening, Aug 2001, 6

Infant abductions, Aug 2001, 4; Jan 2002, 4; Mar 2002, 5; Apr 2002, 11; Oct 2003, 7-8; Jan 2004, 1

communication, Oct 2003, 8

patient education, Oct 2003, 8

prevention, Oct 2003, 7-8

root causes, Oct 2003, 7-8

safe environment, Oct 2003, 7-8

staff training, Oct 2003, 8

Infant death

prevention strategies, Dec 2004, 11

Infection control, Sep 2002, 2; Mar 2003, 3; Apr 2003, 3, 6; Nov 2003, 3; Feb 2004, 3, 4, 7; Oct. 2004, 3-4, 10

and cost reduction, Jun 2005, 1-2, 4

and hand hygiene, Oct. 2004, 3-4, 10

and survey process, Mar 2003, 3; Apr 2003, 3

CDC guidelines, Oct. 2004, 4

functions of, Oct. 2004, 4

reducing central line infection rates, Jul 2005, 9-10

revised standards, Feb 2004, 7

risk assement, May 2005, 4

Infection control expert panel, May 2003, 7

Infection surveillance, Aug 2004, 11; May 2005, 4

Influenza and pneumococcal disease, Sep 2004, 12-13; Aug 2005, 12-13

compliance suggestions, 12-13

Joint Commission requirements, Sep. 2004, 12; Aug 2005, 12-13

National Patient Safety Goals, Dec 2004, 4

reducing risk of, Sep. 2004, 12-13; Aug 2005, 12-13

Information management, Jul 2001, 2; Sep 2001, 2; Jul 2002, 4-5

Information requirements

human factors engineering strategies, Jan 2005, 4

Information sharing, Sep 2001, 7; Apr 2002, 7

Informed consent,Mar 2005, 1-2, 8

definition, Mar 2005, 1

Infusion pumps, Aug 2001, 4; Jan 2003, 9-10; Sep 2003, 9-10; Dec 2003, 7-8; Apr 2004, 4-6; Sep. 2004, 8; Aug 2005, 2, 9

compliance suggestions, Sep 2003, 9; Sep. 2004, 8; Aug 2005, 9

improving use of, Apr 2003, 9-10; Sep 2003, 9-10 ; Apr 2004, 4-6; Sep. 2004, 8; Aug 2005, 9

Joint Commission requirements, Jan 2003, 9-10; Sep 2003, 9-10; Sep. 2004, 8; Aug 2005, 9

risk reduction strategies, Jan 2003, 10

safety, Nov 2002, 11

Ingham Regional Medical Center (Lansing, Michigan), Apr 2005, 9–10

Injectable potassium chloride concentrate, May 2001, 11; Jun 2001, 4

Institute for Healthcare Improvement (IHI)

100,000 Lives Campaign, May 2005, 1-3

Institute for Safe Medication Practices, Jun 2003, 1

and pediatric adverse drug events, May 2005, 9-10

Institute for Safe Medication Practices (ISMP), Sep 2001, 7; Oct 2002, 10

Institute of Medicine (IOM), Jun 2001, 1

Crossing the Quality Chasm, Jun 2001, 1, 3

health literacy skills, Mar 2005, 1

quality challenges, Jun 2001, 3

Institute of Medicine report, Mar 2004, 1

and recommendations to improve work environment, Mar 2004, 2

Insulin, May 2001, 11; Jun 2001, 4

Integration committee, Jun 2004, 1-2

Intensive care unit (ICU), Jan 2004, 9, 11

Intravenous anticoagulants, May 2001, 11; Jun 2001, 4

Isolation, Feb 2004, 4

JCAHO news, Feb 2004, 7-8; Apr 2004, 4-6

and 2004 National Patient Safety Goals, Apr 2004, 4-6

JCAHO standards, Aug 2003, 9-10

Frequently Asked Questions (FAQs), Mar 2005, 7

informed consent, Mar 2005, 1–2, 8

Leadership (LD), Feb 2005, 11

and National Patient Safety Goals, Aug 2003, 9-10

and National Quality Forum, Aug 2003, 9-10

Patient flow, Feb 2005, 11

Safe Practice 10 and health literacy, Mar 2005, 2

Standards Interpretation Group, Feb 2005, 7

surgical site marking, Mar 2005, 7

JCAHO updates, Jun 2002, 3, 7, 10; May 2003, 7-8; Nov 2004, 7-8, 9-10

allergy notification, Jan 2005, 8

compliance with National Patient Safety Goals, Nov 2004, 7-8

congressional hearings participation, Aug 2002, 6, 11

establishment of patient safety goals, Jun 3, 7

infection control expert panel, May 2003, 7

intent statement revisions, Jun 2002, 10

NCQA partnership, May 2003, 8

Nursing Advisory Council, May 2003, 7

patient safety, Nov 2004, 3, 10

performance report revisions, Jun 2002, 10

Periodic Performance Review (PPR), Feb 2005, 3

Sentinel Event Advisory, Feb 2005, 7

Sentinel Event Alert advisory group, Jun 2002, 7, 10

sentinel event data for home care, Nov 2004, 9-10

Sentinel Event Policy, Dec 2004, 11

standards review project, May 2003, 8

Universal Protocol, Nov 2004, 9-10

wrong-site, wrong-procedure, wrong-person surgery summit, May 2003, 8

John M. Eisenberg Patient Safety Awards

2003 winners, Jun 2003, 8

Johns Hopkins Children's Center

research on pediatric adverse events, Nov 2004, 1

Joint Commission International Center for Patient Safety,Mar 2005, 2; Jul 2005, 7

Peter Angood appointed Chief Patient Safety Officer, Jul 2005, 7

Joint Commission Resources Safety Page, Jun 2004, 8

Kaiser Permanente

case study, Apr 2002, 8-9

error reporting and knowledge sharing, Apr 2002, 8-9

leadership support, Apr 2002, 9

safety culture, Apr 2002, 8-9

Kaleida Health

case study, Oct 2002, 8-9

wrong site surgery prevention, Oct 2002, 8-9

Keeping Patients Safe: Transforming the Work Environment of Nurses, Mar 2004, 1-2, 4

Kernicterus, prevention of, Nov 2001, 11

risk reduction strategies, Nov 2001, 11

Knowledge transfer, Oct 2003, 10

Laboratories

clinical alarm systems, Feb 2005, 7

critical tests and results, Apr 2005, 11

Life Safety Code compliance, Feb 2005, 7

Laboratories and patient safety, Oct 2001, 10; Jul 2004, 1-2, 4, 10

analytic processes, Jul 2004, 2, 4

and point-of-care testing, Jul 2004, 1-2, 4

communication, Jul 2004, 4, 10

labeling and identification processes, Oct 2001, 10

postanalytic processes, Jul 2004, 4

preanalytic processes, Jul 2004, 2

specimen collection, Oct 2001, 10; Jul 2004, 4

tips for specimen collection and blood transfusions, Oct 2001, 10

transfusion errors, Jul 2004, 4

Laboratory and Point-of-Care Testing, Apr 2004, 5-6

and 2004 National Patient Safety Goals, Apr 2004, 5-6

Laboratory processes, Sep 2002, 6,10

and patient safety errors, Sep 2002, 6,10

Lagging indicators, Dec 2003, 5-6

Lake Grove at Maple Valley

case study, Jun 2001, 8-9

communication efforts, Jun 2001, 8

monitoring use and frequency of restraints, Jun 2001, 8

performance improvement process, Jun 2001, 8-9

safe alternatives to physical restraint, Jun 2001, 8-9

staff training, Jun 2001, 8

Lance Armstrong Foundation Live Strong yellow rubber wrist bands, Apr 2005, 2

Language barrier,Mar 2005, 8

Latex, Jul 2004, 7-8

allergies, Jul 2004, 7-8

alternatives to, Jul 2004, 7-8

assessing risk of, Jul 2004, 7

latex-free zones, Jul 2004, 7-8

Leadership

and cultural competence, Oct. 2004, 8

and culture of safety, Jul 2001, 1, 3

and effective communication, Jun 2001, 4

and medication safety committee, Dec 2003, 3-4

and staffing requirements in long term care, Oct 2003, 3

and staffing, Sep 2001, 4; Oct 2001, 3

chain-of-command policies, Jan 2005, 6

commitment, Aug 2001, 2, 5

intent statement revisions (LD.5.1), Jun 2002, 10

interview during survey process, Aug 2002, 2

JCAHO expectation, Oct 2003, 6

long term care standards, Feb 2002, 1, 3, 9

Periodic Performance Review (PPR) requirements, Feb 2005, 3

policies and procedures implementation, Mar 2002, 4

responding to patient safety issues, Dec 2004, 8

standards revisions, May 2001, 1, 3

Universal Protocol policies, Feb 2005, 10

Leadership WalkRounds^TM, May 2004, 10

Leading indicators, Dec 2003, 5-6

Leapfrog Group

Guest Commentary, Feb 2002, 6, 9

and the Joint Commission: Survey Similarities of NQF’s Safe Practices, Nov 2004, 3, 10

Legal issues

wrong-site, wrong procedure, wrong-person surgery, Feb 2005, 10

Legionnaires disease, Aug 2004, 7

prevention guidelines, Aug 2004, 7

Lexington Department of Veterans Affairs (VA) Medical Center (Kentucky), Apr 2005, 7

Licensed independent practitioner (LIP)

credentialing and privileging, Nov 2002, 1

Life Safety Code compliance, Feb 2005, 7

Link-to-Life Capsule, Aug 2003, 8, 10

Long term care

and National Patient Safety Goals, Apr 2004, 6

and staffing effectiveness, Oct 2003, 3

care plans, Nov 2002, 6

clinical alarm systems, Feb 2005, 7

credentialing, Nov 2002, 6

data collection, Nov 2002, 6

initial assessments, Nov 2002, 6

Life Safety Code compliance, Feb 2005, 7

pharmacies, Apr 2005, 6

visits to resident care settings, Jun 2002, 2

Look-alike, sound-alike medications, Apr 2005, 4

Low-severity prescriptions, Apr 2005, 3

Management of human resources

policies and procedures implementation, Mar 2002, 4

team training, Mar 2002, 1, 3, 9

Management of information

and effective communication, Jun 2001, 4

Marworth treatment center, Jun 2003, 9-10

Measuring improvement, May 2004, 4

Medical Care and Reduction of Error Act, May 2005, 3

Medical emergency teams (METs), Jan 2005, 9; Mar 2005, 11

Medical equipment defects, Jul 2002, 10

case study, Jun 2003, 8-9

data collection on, Jul 2002, 10

decreasing medication errors through on-time delivery, Jun 2003, 9-10

maintenance and inspection, Jul 2002, 10

safety assessment, Nov 2004, 5-6

Medical error prevention

and electronic medical records, Jul 2005 1-2, 6, 8, 11

and inadequacy of information, Jul 2002, 4

and patient involvement, Jun 2005, 9-10

and patient safety taxonomy, Aug 2002, 1, 3

pediatric adverse events, Nov 2004, 1-2, 4

Medical error reporting, Jul 2001, 7

and staff education, Jul 2001, 7

Medical errors, Jan 2004, 7-8

postdischarge adverse events, Jan 2004, 7-8

Medical Executive Committee,Mar 2005, 3

Medical gases, Jun 2001, 10; Mar 2002, 5; May 2002, 8-9, 11; Aug 2003, 8, 10; Sep 2003, 5-6; Nov 2004, 2, 4

mix-ups, May 2002, 11

Medical history

challenges in pediatric care, Nov 2004, 2

Medical history

transferring of, Aug 2003, 8, 10

Medical liability system, Apr 2005, 3

Medical records

informed consent guidelines, Mar 2005, 1

Medically induced trauma, May 2005, 6

Medically Induced Trauma Support Services (MITSS), May 2005, 6

Medication error prevention

abbreviations, Jan 2002, 11

adequate staffing, Jun 2001, 10

case study, Jan 2005, 9–10

causes of errors, Nov 2004, 2

computerized physician order entry system, Feb 2002, 8-9

conflicting prescriptions, Jan 2005, 8

definition, Jun 2001, 10

dispensing properly, June 2003, 9-10

effective communication, Jun 2001, 10

improvement process, May 2002, 8-9

information sharing, Sep 2001, 7

MedMARx^SM results and improvement opportunities, Sep 2002, 11

National Patient Safety Goals, Dec 2004, 3

on-time delivery, Jun 2003, 9-10

pediatrics, Dec 2001, 10

prevention strategies, Nov 2004, 4

proactive reduction, Jul 2001, 3

reporting, Jul 2001, 3, 6, 7; Oct 2001, 8-9

sound-alike medications, Sep 2001, 2

standardization of drug concentrations, Sep 2003, 6-7

team training, Mar 2002, 1, 3, 9

U.S. Pharmacopeia (USP), Jun 2003, 7-8

Medication errors, Feb 2004, 11; Aug 2004, 5-6; Oct. 2004, 7, 9

and bar codes, Aug 2004, 9-10

and home care, Aug 2004, 5-6

education, Aug 2004, 5-6

improper dose/quantity errors, Aug 2004, 5

pediatric medication errors, 11

reduction of, Oct, 2004, 7, 9

risks for elderly population, Apr 2005, 3

system solution, Aug 2004, 6

types and causes of, Aug 2004, 5

universal medication form, Jun 2005, 10

Medication Errors Reporting (MER),Mar 2005, 3

Medication history

challenges, Jan 2005, 7-8

Medication Management, Jul 2003, 1-2, 9-10; Nov 2003, 3; Feb 2004, 3, 5-6, 10; Mar 2004, 7-8; Jun 2004, 3,6; Sep. 2004, 10-11; Jan 2005, 11; Aug 2005, 11-12

anesthesia awareness, Jan 2005, 11

and evaluation of system, Jul 2003, 2, 9-10

and FMEA, Mar 2004, 7, 8

and National Patient Safety Goals, Jul 2003, 1-2

and priority focus areas, Jun 2004, 3, 6

and risk managers, Feb 2004, 5-6

and system processes, Jul 2003, 1-2, 9-10

checklist, Jun 2004, 3

compliance suggestions, Sep. 2004, 10-11; Aug 2005, 11-12

computerized medication records, Apr 2005, 4

critical processes, Jul 2003, 9

for suicide prevention, Feb 2005, 4

infection control in medication storage bins, Jun 2005, 11

prescription drug claims, Apr 2005, 3

questions and answers, Apr 2005, 4

Medication process team, Apr 2003, 9,10

automated dispensing systems, Aug 2003, 3-4

avoiding prescribing errors, Oct 2002, 2, 6

zero-tolerance ordering standards, Oct 2002, 2

Medication reconciliation process, Apr 2005, 4

Medication safety, Sep. 2004, 6-7; Aug 2005, 7-9

compliance suggestions, Sep. 2004, 7; Aug 2005, 8-9

Joint Commission requirements, Sep. 2004, 6-7; Aug 2005, 8

Medication safety committee, Dec 2003, 3-4

implementation of, Dec 2003, 3-4

maximizing potential, Dec 2003, 3-4

Medication Station, Dec 2003, 3-4; Mar 2004, 7, 8; Jun 2004, 3, 6; Oct. 2004, 7, 9

and conducting FMEA for medication management, Mar 2004, 8-9

medication management as a priority focus area, Jun 2004, 3, 6

medication safety committee, Dec 2003, 3-4

reducing medication errors, Oct. 2004, 7, 9

Medication storage bins

and infection control, Jun 2005, 11

Medication use, Aug 2002, 7; Mar 2003, 3

for ambulatory care, Nov 2002, 3

for behavioral health, Nov 2002, 3

for hospitals, Nov 2002, 6

for RUS topics, Apr 2003, 3, 6

pharmacists’ role in performance improvement, Aug 2002, 7

and survey process, Mar 2003, 3

Medication-related sentinel events, Jun 2001, 4

Medications

delivery of, Oct. 2004, 7

evaluation on safety, Mar 2003, 3

goals of, Jun 2004, 3

high-alert, May 2001, 11

injectable potassium chloride concentrate, May 2001, 11

insulin, May 2001, 11

intravenous anticoagulants, May 2001, 11

Joint Commission requirements, Sep. 2004, 10; Aug 2005, 11-12

opiates and narcotics, May 2001, 11

preparation of, Oct. 2004, 7

process of, Mar 2004, 7

reconciling medications, Sep. 2004, 10-11; Aug 2005, 11-12

safety improvement, Jul 2001, 6

strategies for implementation, Jun 2004, 3, 6

sodium chloride solutions, May 2001, 11

USP recommendations

verbal orders for, Oct. 2004, 7

MEDMARX^SM,Mar 2005, 3

Minimum data sets, Jul 2001, 2

Minnesota Hospital Association, Apr 2005, 8

Mission St Joseph's Health System, Apr 2003, 9,10

Missouri Baptist Medical Center (MBMC)

case study, Nov 2002, 8–9

patient safety program, Nov 2002, 8–9

Mock code

medical emergency team (MET) approach, Mar 2005, 11

Monitoring compliance, Nov 2003, 7-8

National Patient Safety Goals, Nov 2003, 7-8

National Committee for Quality Assurance (NCQA), May 2003, 8

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), June 2003, 1-2

National Patient Safety Foundation, Oct 2002, 10

Speak Up for Patient Safety, Oct 2002, 10

Web site, Oct 2002, 10

National Patient Safety Goals, Sep 2002, 1,3; Nov 2002, 8-9; Jan 2003, 1-11; Mar 2003, 2; April 2003, 1, 2, 4; June 2003, 1-2, 4; Jul 2003, 3-4, 10; Aug 2003, 9-11; Sep 2003, 1-11; Nov 2003, 3, 7-8; Dec 2003, 7-8; Jan 2004, 10-11; Feb 2004, 8; Apr 2004, 4-6; Jul 2004, 4; Aug 2004, 11; Sep. 2004, 1-15; Oct. 2004, 11; Nov 2004, 7-8; Aug 2005, 1-15

2004 program-specific changes to, Apr 2004, 4-6

2005 program-specific changes to, Sep. 2004, 1-15

2006 program-specific changes to, Aug 2005, 1-15

abbreviation standardization, May 2005, 3; Aug 2005, 5

alarm systems, Jan 2003, 10-11; Sep 2003, 10; Sep. 2004, 8-9; Aug 2005, 9

alternative approaches, Jan 2003, 2-3; Sep 2003, 2-3; Sep. 2004, 2; Aug 2005, 3

and home care, Feb 2004, 8; Aug 2005, 8, 11, 12

and nursing, Dec 2003, 7-8

and read-back results, Jul 2004, 4, Aug 2005, 6-7

and the IHI 100,000 Lives Campaign, May 2005, 1-3

communication effectiveness, Jan 2003, 4-6; Sep 2003, 5-6; Sep. 2004, 4-6; Aug 2005, 4-7

communication strategies, Feb 2005, 1

compliance data results, Jun 2003; 1-2, 4; Nov 2004, 7-8

compliance with, Jan 2003, 2; Mar 2003, 2

correlation to NQF’s Safe Practices, Aug 2003, 9-11

definition of sentinel event, Apr 2005, 8

documentation of, Sep. 2004, 1; ug 2005, 1-2

falls, Sep. 2004, 11; Aug 2005, 12

fire prevention, Feb 2005, 6

for 2005, Feb 2005, 7

for 2006, Aug 2005, 1-15

Goal 11a, Oct. 2004, 11

Goal 7b, Aug 2004, 11

compliance strategies for, Aug 2004, 11

health care-acquired infections, Sep 2003, 10-11

health care-associated infections, Sep. 2004, 9-10; Aug 2005, 9-10

high-alert medications, Jan 2003, 6-8; Sep 2003, 6-7

implementation of, Sep. 2004, 14-15; Dec 2004, 7; Aug 2005, 1-2

influenza and pneumococcal disease, Sep. 2004, 12-13; Aug 2005, 12-13

infusion pump safety, Jan 2003, 9-10; Sep 2003, 9-10; Sep. 2004, 8; Aug 2005, 9

Joint Commission requirements, Sep. 2004, 2-15; Aug 2005, 2-15

list of look-alike, sound-alike medications, Apr 2005, 4

medication management, Sep. 2004, 6-7; 10-11; Apr 2005, 4; Aug 2005, 7-9, 11-12

medication reconciliation process, Apr 2005, 4

monitoring compliance with, Nov 2003, 7-8

patient identification, Jan 2003, 3-4; Sep 2003, 4-5; Sep. 2004, 3-4; Apr 2005, 1–2; Aug 2005, 3-4

patient/family involvement in patient safety, Aug 2005, 14

pressure ulcers, prevention of, Aug 2005, 14-15

rationale and interpretive guidelines, Dec 2004, 3-4

scoring of, Sep 2003, 3; Sep. 2004, 2; Aug 2005, 2

staff compliance with, Jul 2003, 3-4, 10

standardized abbreviations, Jun 2003, 1-2, 4; Jan 2004, 9, 11

surgical fires, Sep. 2004, 13; Aug 2005, 13

surgical site marking, Mar 2005, 7

timely report and receipt of critical tests and results, Apr 2005, 11

time-out before surgery, Jun 2003, 1-2, 4

type I recommendations, Sep 2002, 1

universal protocol for preventingwrong site, wrong procedure, wrong person surgery, Sep. 2004, 7-8; Aug 2005, 15

wrong-site, wrong-patient, wrong-procedure surgery, Jan 2003, 8, 9; Jun 2003, 1-2, 4; Sep 2003, 7-8

National Quality Forum, Aug 2003, 9-11; Nov 2004, 3, 10

consensus report, Aug 2003, 9-10

correlation of safe practices, Aug 2003, 11; Nov 2004, 3, 10

informed consent, Mar 2005, 1–2, 8

Safe Practice 10, Mar 2005, 2

Safe Practices for Better Healthcare, Mar 2005, 2

National Strategy for Suicide Prevention: Goals and Objectives for Action (NSSP), Aug 2001, 11

National Summit on Medical Abbreviations, May 2005, 3

National Time Out Day, Feb 2005, 10

Near misses, Oct 2001, 4-5

benefits of, Oct 2001, 4

enhancing patient safety through reporting, Oct 2001, 8-9

reporting form, Oct 2001, 9

root cause analysis, Oct 2001, 4-5

Needlestick prevention program, Dec 2001, 11

North Colorado Medical Center (NCMC)

wrong-site-surgery policy, Feb 2005, 9–10

Northeast Methodist Hospital

case study, Dec 2001, 8-9

near misses, Dec 2001, 8-9

wrong-site surgeries, Dec 2001, 8-9

Nosocomial infections, Apr 2003, 11; Sep 2003, 11

Nursing, Dec 2003, 7-8; Mar 2004, 1-2, 4

and caregiver communication, Dec 2003, 7

and clinical alarm systems, Dec 2003, 8

and health care-associated infections, Dec 2003, 8

and high-alert medications, Dec 2003, 8

and IOM recommendations, Mar 2004, 2

and National Patient Safety Goals, Dec 2003, 7-8

and patient identification, Dec 2003, 7

and patient safety, Mar 2004, 1-2, 4

and work environment, Mar 2004, 1

and wrong site, wrong procedure, wrong person surgeries, Dec 2003, 8

Nursing Advisory Council, May 2003, 7

Nursing leadership interview, Feb 2002, 2

Nursing shortage, Mar 2004, 4

Obesity, Jul 2004, 11

obese patients, Jul 2004, 11

providing care for, Jul 2004, 11

Office of Quality Monitoring (OQM) hotline, Aug 2001, 7; Oct 2001, 2

submitting a complaint, Jun 2005, 3, 8

Office-based surgery

critical tests and results, Apr 2005, 11

fire prevention, Feb 2005, 6

National Patient Safety Goals, Feb 2005, 7

Ohio Patient Safety Institute (OPSI) and Ohio Hospital Association (OHA), Nov 2004, 9

case study, Nov 2004, 9-10

wrong-site surgery, Nov 2004, 9-10

Ongoing competence, Jun 2004, 6

On-site surveys, May 2004, 8

Operative and postoperative complications, Jun 2001, 5; Oct 2001, 11; Nov 2001, 10; Mar 2003, 11

Opiates and narcotics, May 2001, 11; Jun 2001, 4

Organ donation, Jul 2004, 3

hospital standard for, Jul 2004, 3

Organ donor program, Jul 2004, 3

Organizational culture, May 2004, 1

Organizational culture strategies, Apr 2004, 7

Organizational initiatives, Apr 2003, 7, 8

Orientation and training of staff, May 2001, 2; May 2002, 4-5; Nov 2002, 6; Dec 2003, 2-4; Jul 2004, 5-6

and float or contracted staff, Jul 2004, 5-6

and sentinel events, May 2001, 2

buddy/team system, Jul 2004, 6

departmental orientation, Jul 2004, 6

job-specific orientation, Jul 2004, 6

ORYX measures, patient safety practices, Nov 2004, 3

Outpatient claims database, Apr 2005, 3

Outpatient facilities, Mar 2003, 5-6, 8

Outpatient services

patient medications, Apr 2005, 4

Overcrowding, Jun 2004, 11

prevention of, Jun 2004, 11

Overrides policy, Aug 2003, 3-4

avoiding errors, Aug 2003, 4

compliance with, Aug 2003, 4

Over-the-counter medications, Jan 2005, 8

Part of the Oath: The Physician's Role in Medication Safety, Jan 2005, 7–8

Patient and family education, Apr 2004, 8, 11

Patient assessment, Nov 2001, 4-5; Dec 2003, 1-2

adequacy and timeliness of, Dec 2003, 1-2

in emergency departments, Dec 2002, 1, 3

proper assessment, Dec 2002, 2002, 2

Patient care

patient/family involvement in, Aug 2005, 14

Patient care assistants, Dec 2004, 9-10

Patient communication, Dec 2003, 2

Patient education, Nov 2001, 7; Aug 2003, 2; Oct 2003, 8; Nov 2004, 4

anesthesia awareness, Jan 2005, 11

and home care, Aug 2003, 2

and infant abductions, Oct 2003, 8

Patient flow

assessing compliance, Feb 2005, 11

Patient identification, Jan 2003, 3-4; Sep 2003, 4-5; Nov 2003, 9-10; Dec 2003, 7, 11; Jan 2004, 5-6; Apr 2004, 4; Sep. 2004, 3-4; Oct. 2004, 7; Aug 2005, 3-4

and medication distribution, Oct. 2004, 7

blood transfusion errors, Jan 2004, 5-6

case study, Nov 2003, 9-10

color verification system, Nov 2003, 9-10

ID badge program, Nov 2003, 10

registration process, Nov 2003, 9

compliance tip, Jan 2003, 3; Sep 2003, 4-5; Sep. 2004, 3-4; Aug 2005, 4

identifier suggestions, Jan 2003, 3-4

Joint Commission requirements, Jan 2003, 3, 4; Sep 2003, 4; Sep. 2004, 3-4; Aug 2005, 3-4

patient-based product identification, Jan 2003, 4

setting-specific tips, Sep 2003, 4

surgical verification, Jan 2003, 4

tips for improvement, Dec 2003, 11

Patient isolation, Jun 2004, 7-8

and health care–associated infections, Jun 2004, 7

and intervention components, Jun 2004, 8

education, Jun 2004, 8

psychological impact of, Jun 2004, 8

research outcomes, Jun 2004, 8

safety risks, Jun 2004, 7-8

Patient monitoring, Oct. 2004, 7

Patient participation, May 2003, 1-2, 4

intent statement revisions (RI.1.2.2), Jun 2002, 10

patient safety standards, Apr 2003, 2, 4

Patient risks and home care, Aug 2003, 2

Patient safety, Mar 2003, 5-6, 8; Apr 2004, 11

anesthesia awareness, Jan 2005, 11

best practices, Feb 2005, 3

case study, Dec 2004, 9-10

employees' opinions of, Mar 2005, 5–7

engaging patients in, Apr 2004, 11

enhancing, Feb 2005, 8

home safety assessment, Nov 2004, 5–6

language barriers, Mar 2005, 8

medical emergency team (MET) approach, Mar 2005, 11

and medically induced trauma, May 2005, 6

National Quality Forum (NQF) safe practices, Nov 2004, 10

and plastic surgery, Mar 2003, 5–6, 8

SBAR technique, Feb 2005, 1–2, 8

suicide prevention, Feb 2005, 4, 6

technology

measuring effectiveness, Apr 2005, 10

patient identification, Apr 2005, 1–2, 10

strategies, Apr 2005, 2, 10

tools for, Apr 2004, 11

Patient safety and in-house laboratories, Oct 2001, 10

Patient Safety Center of Inquiry

case study, May 2001, 8-9

data collection, May 2001, 9

human factors and medical equipment, May 2001, 9

safety and clinical research interaction, May 2001, 9

sleep deprivation and fatigue effects, May 2001, 9

teamwork and simulation training, May 2001, 8

workgroup cultures, May 2001, 9

Patient safety challenges, Jan 2004, 8

and discharged patients, Jan 2004, 8

Patient Safety Committee, Aug 2001, 1-2, 5

key attributes, Aug 2001, 1-2, 5

patient participation in, May 2003, 1-2, 4

Patient safety committees, Jun 2004, 1-2, 4

conserving resources, Jun 2004, 2

integration of, Jun 2004, 2, 4

process of, Jun 2004, 4

Patient safety council, Jun 2004, 2

Patient safety education, Mar 2004, 9-10

Patient involvement in anesthesia safety, Mar 2004, 11

Patient safety indicators, Dec 2003, 5-6

Patient safety legislation, Jun 2003, 7

Patient safety taxonomy, Aug 2002, 1, 3

Patient safety Web site, Jul 2004, 6

Patient suicide, Jan 2004, 1-2

in adolescents, Jan 2004, 1-2

prevention, Jan 2004, 2

Patient transfers

in emergency departments, Dec 2003, 3, 9

Patient/caregiver education, Aug 2004, 5-6

and medication errors, Aug 2004, 5-6

Pediatric adverse events

preventing infant death and injury during delivery, Dec 2004, 11

strategies for eliminating, Nov 2004, 1–2, 4

Pediatric emergency tape, May 2005, 9-10

Pediatric medication errors, Dec 2001, 10; Feb 2004, 11

prevention of, Feb 2004, 11

Pediatric populations, Jan 2004, 1

Pediatrics,Mar 2005, 3

Performance improvement

and adverse events prevention, Jun 2001, 7

and benchmarking, Mar 2002, 7

and Communication Priority Focus Area, 7-8

and cost effectivness, Oct 2002, 7

and data collection, Dec 2002, 10

and data management, Jul 2001, 2

and defining error, June 2003, 3-4

and development of safety program, Sep 2001, 1, 3

and human factors, Dec 2002, 10

and improving patient safety, Apr 2003, 5, 6; Dec 2003, 5-6

and incident reports, Oct 2001, 7

and information sharing, Sep 2001, 7

and medication errors, Jun 2003, 9-10

and near misses, Oct 2001, 4-5, Oct 2001, 8-9

and patient education, Nov 2001, 7

and patient safety standards, Apr 2003, 4

and Priority Focus Process, Apr 2004, 2

and risk management professionals, May 2001, 7

and root cause analysis, May 2003, 5-6

and safety standards, Apr 2004, 3

and safety, Jul 2002, 2

and staff orientation, Jan 2002, 7

and staffing effectiveness, Oct 2001, 3

pharmacists’ role and medication use process, Aug 2002, 7

PI tools, May 2002, 7

cause-and-effect diagrams, May 2002, 7

flowcharts, May 2002, 7

interrelationship diagrams, May 2002, 7

policies and procedures, Mar 2002, 4-5

prioritization of activities, Oct 2002, 7

reducing fall rates, Nov 2003, 5-6

requirements, Feb 2005, 3

standards requirements, Jul 2002, 2

standards revisions, May 2001, 3

Performance measurement

patient safety, Dec 2004, 1-2, 8; Jan 2005, 10

resources, Dec 2004, 8

utilities management strategies, Dec 2004, 6, 8

Performance measures, Dec 2003, 5-6

Performance report revisions, Jun 2002, 10

Periodic Performance Review, May 2004, 3, 8

assessing compliance, Feb 2005, 3

options, May 2004, 3, 8

Persons United Limiting Substandrads and Errors in Health Care (PULSE), Jul 2005, 3-4

Pharmaceutical issues

back orders, Mar 2005, 3–4

challenges in pediatric care, Nov 2004, 4

purchasing agent, Mar 2005, 4

Pharmacists and medication use process, Aug 2002, 7; May 2003, 4-5; Aug 2003, 3-4

CPOE, May 2003, 4-5

monitoring prescriptions, Apr 2005, 3

prescription reviews, Aug 2003, 3-4

role in medication histories, Jan 2005, 7–8

Pharmacy & Therapeutics (P&T) Committee,Mar 2005, 3

Physical assessment

challenges in pediatric care, Nov 2004, 2

Physical environment, Dec 2003, 4

Physician involvement

and root cause analysis, Sep 2001, 10

in safety initiatives, Apr 2003, 7, 8

Physicians

ethical responsibilities, Apr 2005, 8

Pilot tests

medical emergency team (MET) approach, Mar 2005, 11

Plastic surgery, Mar 2003, 5–6, 8

facilities and equipment, Mar 2003, 5–6

patient and procedure selection, Mar 2003, 6

and patient care, Mar 2003, 6, 8

provider qualifications, Mar 2003, 5

Pneumonia, Aug 2004, 7-8

prevention guidelines, Aug 2004, 7-8

risk of, Aug 2004, 7

Point-of-care testing, Jul 2004, 1-2, 4

Polypharmacy, Jan 2004, 2

Post traumatic stress disorder, Oct 2003, 5-6

Postdischarge adverse events, Jan 2004, 7-8

Postoperative complications. See Operative and postoperative complications and Sentinel Event Alert

Potassium chloride (KCl), Aug 2001, 4

Power failure

utilities management strategies, Dec 2004, 6

Premier, Inc.

measuring organizational conditions, Mar 2005, 5

Preoperative verification process, Sep 2003, 7-8; Nov 2003, 1-2; Sep. 2004, 7; 14-15; Aug 2005, 15

Preprinted prescription forms, Dec 2003, 9-10

creation of, Dec 2003, 9

examples of, Dec 2003, 10

testing, Dec 2003, 9

usage of, Dec 2003, 9

Prescribing errors, May 2003, 3-4

Pressure ulcers

prevention of, Jul 2005, 3-4; Aug 2005, 14-15

stages of, Jul 2005, 4

Prevention costs, Jun 2001, 7

Prioritizing, Feb 2004, 10

Priority focus areas, Oct 2003, 1-2; Nov 2003, 3; Dec 2003, 1-2, 4; Apr 2004, 1-2, 6; Jun 2004, 3, 6; Oct. 2004, 2-4, 10

and infection control, Oct. 04, 2-4, 10

and medication management, Jun 2004, 3, 6

and patient safety, Apr 2004, 1-2, 6

assessment and care/services, Dec 2003, 1

communication area, Apr 2004, 7-8

communication, Dec 2003, 2

orientation and training, Dec 2003, 2-4

physical environment, Dec 2003, 4

system tracer activities, Feb 2005, 3

Priority focus process (PFP), Oct 2002, 3; Feb 2004, 3; Apr 2004, 1-2, 6; May 2004, 8

and PFP report, Apr 2004, 2

and tracer activities, May 2004, 8

goal of, Oct 2002, 3

priority focus tool, Oct 2002, 3

Proactive risk assessment, Dec 2001, 4; Apr 2003, 2, 4; Aug 2003, 2

and home care, Aug 2003, 2

Proactive risk-reduction strategies, Aug 2001, 4; Aug 2003, 1-2

Processes, Aug 2002, 4–5; Aug 2003, 1-3

characteristics of, Aug 2002, 4

complexity, Aug 2002, 4

definition of, Aug 2002, 4

evaluation of, Aug 2003, 1-3

failure mode and effects analysis (FMEA), Aug 2002, 4

high-risk, Aug 2002, 4

latent conditions, Aug 2002, 5

loosely coupled, Aug 2002, 5

tight coupling, Aug 2002, 4–5

Program for Monitoring Emerging Diseases (ProMED), May 2005, 4

Project planning

task time line, Mar 2005, 6

Project teams

medical emergency team (MET) approach, Mar 2005, 11

Provision of care, treatment, and services standards, Jan 2004, 3-4

processes of, Jan 2004, 3-4

Psychotherapy

suicide prevention, Feb 2005, 4

Punitive Reporting, Apr 2003, 6

Quaboag Valley Visiting Nurse Association

FMEA on initiation of home infusion, Mar 2005, 9–10

Quality care units, Apr 2005, 1

Quality improvement program, Jan 2004, 9, 11

and reducing bloodstream infection rates, Jan 2004, 9, 11

Quality, business case for, Aug 2004, 2, 4

Radiation injuries, Jul 2002, 1, 3

Radio frequency identification (RFID), Apr 2005, 2

Rancho Los Amigos National Rehabilitation Center

case study, Feb 2002, 8-9

computerized physician order entry system, Feb 2002, 8-9

Random unannounced survey, Jun 2001, 2; Nov 2002, 1, 3, 6; Jul 2003, 3-4, 10; Nov 2003, 3; May 2004, 8

and ambulatory care, Nov 2002, 1, 3

and behavioral health, Nov 2002, 3

and compliance data results, Jul 2003, 3-4, 10

and hospitals, Nov 2002, 3, 6

and long term care, Nov 2002, 6

and patient safety, May 2004, 8

practical strategies, Apr 2003, 3, 6

topics, Nov 2003, 3

Rapid response teams

and the IHI 100,000 Lives Campaign, May 2005, 1-3

Read-back verification process, Sep. 2004, 4; Aug 2005, 4

Reassessment, Jun 2004, 6

Reporting and analysis, Feb 2004, 9-10

and reduction of adverse drug events, Feb 2004, 9-10

Reporting medical errors, Aug 2003, 1-2; Sep 2003, 11

Request for Review of an Alternative Approach, Apr 2005, 4; Jun 2005, 7-8

Resident fatigue, May 2005, 8

Respiratory infections, Aug 2004, 7-8

Prevention guidelines, Aug 2004, 7-8

Respiratory syncytial virus (RSV), Aug 2004, 8

prevention guidelines, Aug 2004, 8

Responding to the Patient Safety Imperative, Jun 2001, 6

Restraint and seclusion, May 2004, 5-6

and patient assessment, May 2004, 5-6

standards, May 2004, 5

Restraint deaths, Aug 2001, 4; Jan 2002, 4-5

prevention of, Feb 2002, 7

Restraint use, Apr 2002, 10; Jul 2003, 7-8, 10; Mar 2004, 5-6, 10

alternatives to, Jul 2003, 7-8, 10; Mar 2004, 6

application of, Mar 2004, 5

documenting use of, Jul 2003, 8

educating staff, Jul 2003, 8, 10

and fall prevention, Dec 2002, 6-7

emergency management, Apr 2002, 10

fire drills, Apr 2002, 10

fire safety, Apr 2002, 10

injuries, Mar 2004, 5

reducing the use of, Jul 2003, 7-8, 10; Mar 2004, 6, 10

restraint-related errors, Mar 2004, 5-6, 10

root causes, Mar 2004, 5-6, 10

staff training, Apr 2002, 10; Mar 2004, 5

Resurrection Healthcare System, Apr 2003, 7

Rights

and communication with patient, Sep 2002, 7,11

and risk management, Sep 2002, 7,11

Risk assessment

home safety, Nov 2004, 5–6

Risk management, May 2001, 7; Feb 2002, 4-5; Apr 2002, 7; Jun 2002, 6; Jul 2002, 7; Sep 2002, 7,11; Mar 2003, 4; Oct 2003, 5-6; Feb 2004, 5-6; Jun 2004, 7-8

and employee assistance programs, Oct 2003, 6

and patient isolation, Jun 2004, 7-8

and performance improvement professionals, May 2001, 7

and post traumatic stress disorder, Oct 2003, 5-6

and resident fatigue, May 2005, 5

and root cause analysis, Mar 2003, 4

and safety program, Sep 2001, 3

and sentinel events, Oct 2003, 5-6

and staffing effectiveness, Oct 2003, 5-6

care recipient rights, Sep 2002, 7,11

communication issues, Nov 2002, 7, 10

emergency management, Feb 2002, 7

failure mode, effects, and criticality analysis (FMEA), Jul 2002, 7

incident reports, Oct 2001, 7

information sharing with risk managers, Apr 2002, 7

patient involvement, Dec 2001, 7

reporting medical errors, Jul 2001, 7

risk managers and medication management, Feb 2004, 5-6

Risk reduction, Aug 2004, 11

Roller latches, Feb 2004, 8

Roncalli Health Care Management

case study, Sep 2001, 8-9

competency testing, Sep 2001, 8

errors and sentinel events, Sep 2001, 8

long term care quality improvement, Sep 2001, 8-9

Quality Improvement Profile Report (QIPR), Sep 2001, 8

quality initiatives, Sep 2001, 9

resident and employee satisfaction, Sep 2001, 8

risk management and safety, Sep 2001, 8

Root cause analysis

analysis tools, Feb 2002, 4-5; Apr 2002, 4-5

and inclusion, Mar 2003, 4

and medication errors, Jul 2001, 6

and patient elopement, May 2004, 9-10

brainstorming, Apr 2002, 5

cause-and-effect diagrams, Feb 2002, 4

failure mode, effects, and criticality analysis (FMECA)

Fault Tree Analysis (FTA), Feb 2002, 5

fishbone diagrams, Feb 2002, 4

flowcharts, Feb 2002, 4; Apr 2002, 4

matrix diagrams, Feb 2002, 4

multiple root causes, Feb 2002, 4-5

multivoting, Apr 2002, 5

tips for success, Apr 2002, 4-5

and proactive risk assessment, Dec 2001, 4

barriers to, May 2001, 4-5; Sep 2001, 10

fear of retribution, May 2001, 4-5

insufficient time, May 2001, 4

staff involvement, May 2001, 4

completion of process, May 2001, 5

compliance inconsistencies, Mar 2002, 4-5

definition of, Dec 2001, 4

failure mode and effects analysis (FMEA), Jun 2002, 4-5; Aug 2002, 4; Oct 2002, 4-5; Mar 2003, 7-8

human factors engineering strategies, Jan 2005, 1–2, 4

in reporting a sentinel event, Oct 2001, 2

involving individuals, Oct 2003, 5

learning from near misses, Oct 2001, 4-5, 8-9

patient identification process, Apr 2005, 10

physician involvement, Sep 2001, 10

processes

complexity, Aug 2002, 4

high-risk characteristics, Aug 2002, 4

latent conditions, Aug 2002, 5

loosely coupled, Aug 2002, 5

tight coupling, Aug 2002, 4–5

protection of information, Mar 2003, 4

RCA results and implementation, May 2003, 5-6, 10

staff competency, Nov 2002, 4-5, 10

team composition, Jul 2001, 4-5; Dec 2001, 4-5

barriers, Jul 2001, 4

changes to, Jul 2001, 5

physician participation, Jul 2001, 4

sample of, Jul 2001, 5

size of, Jul 2001, 5

use of, Dec 2001, 4

Root causes, Jun 2001, 4-5; Aug 2001, 9-10; Sep 2001, 4-5; Nov 2001, 4-5; May 2002, 4-5; Jul 2002, 4-5; Sep 2002, 4-5; Apr 2003, 5, 6; Jun 2003, 5-6, 8; Oct 2003, 7-8; Jan 2004, 5-6; Mar 2004, 5-6, 10; Jun 2004, 5-6; Aug 2004, 5-6

and availability of information, Jul 2002, 4–5

and inaccurate information, Jul 2002, 4–5

and medical/clinical record review, Jul 2002, 4-5

and percentages of sentinel event types, Aug 2001, 9

assessment key to reducing risk of elopement, Jun 2004, 5-6

blood transfusion errors, Jan 2004, 5-6

causes of falls, Jun 2003, 5-6, 8

communication improvements, Jun 2001, 4-5

failures in home infusions, Mar 2005, 9–10

improving patient assessment to prevent errors, Nov 2001, 4-5

infant abductions, Oct 2003, 7-8

medication errors in home care, Aug 2004, 5-6

organizational culture, Apr 2003, 5, 6

overcoming communication barriers, Sep 2002, 4-5

restraint-related errors, Mar 2004, 5-6, 10

staff orientation and training, May 2002, 4-5

staffing effectiveness and error reduction, Sep 2001, 4-5

standards corresponding to, Aug 2001, 10

Rounds, May 2004, 1-2, 4

Rule of Six, the, May 2005, 9-10

and pediatric emergency tape, May 2005, 9

and reduction of adverse drug events, May 2005, 9-10

Safety

business case for, Aug 2004, 2, 4

and performance improvement, Jul 2002, 2

data analysis, Jul 2002, 2

data collection, Jul 2002, 2

planning, Jul 2002, 2

standards revisions, Jul 2002, 2

checklists, Mar 2003, 9–10

information resources, Mar 2002, 7

Safety procedures, Apr 2004, 11

involving patients in, Apr 2004, 11

Safety program, Sep 2001, 1, 3

communication effectiveness, Sep 2001, 1, 3

and data collection, Sep 2001, 1

development of, Sep 2001, 1, 3

reporting processes, Sep 2001, 3

risk management, Sep 2001, 3

Safety risks, Jun 2004, 7

and patient isolation, Jun 2004, 7-8

reduction of, Jun 2004, 7-8

safety-related RUS topics, Apr 2003, 3, 6

staffing effectiveness requirements, Oct 2003, 3

SARS, Feb 2004, 1-2

SBAR. See Situation-Background-Assessment-Recommendation

Scheduling and staffing strategies, May 2003, 9-10

Schizophrenia, Feb 2005, 4, 6

Security, May 2004, 9-10

and patient elopement, May 2004, 9-10

Self-assessment process, Oct 2002, 1, 3

SEM Haven Health and Residential Care Center

case study Mar 2002, 8-9

fall prevention, Mar 2002, 8-9

Sentinel Event Advisory, Feb 2005, 7

Sentinel Event Advisory Group, Sep. 2004, 1; Aug 2005, 1

and National Patient Safety Goals, Sep. 2004, 1; Aug 2005, 1

Sentinel Event Alert, Aug 2001, 3-4, 7, 10; Jan 2002, 5; Jun 2002, 3; Sep 2002, 1,3; Oct 2003, 5-6

advisory group, Jun 2002, 7, 10; Sep 2002, 1,3

blame-free culture, Oct 2003, 6

fires in home care, Sep 2001, 11

human resources involvement, Oct 2003, 6

National Patient Safety Goals, Sep 2002, 1,3

post traumatic stress disorder, Oct 2003, 5-6

restraint-related deaths, Feb 2002, 11

root cause analysis, Feb 2002, 4

sign-up information, Aug 2001, 10

suggested safety strategies, Aug 2001, 3-4

fatal falls, Aug 2001, 4

high-alert meds, Aug 2001, 3

infant abductions, Aug 2001, 4

infusions pumps, Aug 2001, 4

kernicterus, Nov 2001, 11

needlestick injuries, Dec 2001, 11

operative and postoperative complications, Aug 2001, 3

potassium chloride (KCI), Aug 2001, 4

proactive risk-reduction strategies, Aug 2001, 4

restraint deaths, Aug 2001, 4; Feb 2002, 11

suicide, Aug 2001, 3

transfusion events, Aug 2001, 4

wrong-site surgery, Aug 2001, 3

Sentinel Event Database, May 2004, 11

Sentinel Event Hotline, Oct 2001, 2

Sentinel event policy, Aug 2004, 11; Dec 2004, 11; Jul 2005, 5-6

Sentinel event statistics, May 2004, 11; May 2005, 11

Sentinel events

blood transfusion errors, Mar 2002, 5

complaint data, Aug 2002, 10–11

definition, Apr 2005, 8

and failure mode and effects analysis, May 2005, 8

falls, Jun 2001, 11

in home care, Nov 2004, 5

infant abductions, Jan 2002, 4-5; Mar 2002, 5

infection-related, Aug 2004, 11

and laboratory processes, Sep 2002, 6,10

medication-related, Jun 2001, 4; Mar 2002, 5

near misses, Oct 2001, 4-5

operative and postoperative complications, Nov 2001, 10

outcomes, number, and percentage, Aug 2001, 8

policy and procedure tips, Mar 2002, 5

reporting of, Oct 2001, 2; Sep 2003, 11; Jul 2005, 5-6

root causes and percentages, Aug 2001, 9

settings, Aug 2001, 8

statistics, May 2003, 11

restraint deaths, Jan 2002, 4-5; Feb 2002, 11

reviewable, Apr 2005, 8

and staffing effectiveness, Sep 2001, 4-5

standards corresponding to root causes, Aug 2001, 10

type, number, and percentage, Aug 2001, 8

statistics, Aug 2001, 7-10; Aug 2002, 10-11

suicide, Jun 2001, 5; Jan 2002, 4-5

teamwork approach response to, May 2002, 6

wrong-site surgery, Jun 2001, 5; Mar 2002, 5, 11

Shared Visions-New Pathways, Oct 2002, 1, 3, 9; Dec 2003, 1

Signs-and-symptoms cards, Oct. 2004, 5-6, 10

sample cards, Oct. 2004, 6, 10

Site marking, Sep. 2004, 8; 14-15; Aug 2005, 15

Situation-Background-Assessment-Recommendation

communication strategies, Feb 2005, 1

and improving hand-off comunication, Jul 2005, 11

Sleep depravation, Mar 2004, 3; May 2005, 5

and staff, Mar 2004, 3

Smoke detectors, Nov 2004, 5

Smoking

home safety issues, Nov 2004, 6

Sodium chloride solutions, May 2001, 11; Jun 2001, 4

Speak Up campaign, Jun 2002, 1, 3; Oct 2002, 10; Apr 2004, 8; Jul 2004, 3

and organ donation, Jul 2004, 3

Special patient populations, Jan 2004, 1-2, 4

adolescent populations, Jan 2004, 1-2

cognatively impaired populations, Jan 2004, 2, 4

ensuring safety of, Jan 2004, 1-2, 4

geriatric populations, Jan 2004, 2

pediatric populations, Jan 2004, 1

Specimen collection and patient safety, Oct 2001, 10

tips for collection, Oct 2001, 10

Spirituality, Feb 2005, 5–6

St Joseph Hospital West

case study, Oct 2001, 8-9

near miss form, Oct 2001, 9

near miss reporting program, Oct 2001, 8-9

Staff

adequacy of staffing and error reduction, Sep 2001, 4-5

alertness of, Mar 2004, 3

competence assessment, May 2002, 5

competency, May 2001, 2; Nov 2002, 4-5, 10

error reporting, Jul 2001, 7; Aug 2003, 1-2

involvement in root cause analysis, May 2001, 4

naps during breaks, Mar 2004, 3

orientation and training, May 2001, 2; May 2002, 4-5; Mar 2004, 5

shortages, Apr 2002, 1, 3

sleep depravation, Mar 2004, 3

strategies, May 2003, 9-10

Staff assignments, Jul 2004, 6

Staff education, May 2004, 7; Aug 2004, 6' Nov 2004, 11

anesthesia awareness, Jan 2005, 11

chain-of-command policies, Jan 2005, 6

communication issues, Nov 2004, 11

fire prevention, Feb 2005, 5–6

health literacy skills, Mar 2005, 8

medical emergency team (MET) approach, Mar 2005, 11

and medication errors, Aug 2004, 6

patient identification, Apr 2005, 9

Universal Protocol, Feb 2005, 10

utilities management strategies, Dec 2004, 6, 8

volunteer training, may 2004, 7

Staff training, Sep 2003, 11

changes to, May 2004, 3

Staffing

credentials of temporary or volunteer staff, Apr 2005, 6

Staffing effectiveness, Oct 2001, 1, 3, 5; Oct 2003, 3; Nov 2003, 3; Feb 2004, 2; Mar 2004, 3-4

assessing staffing plans, Mar 2004, 3

compliance, Oct 2001, 3, 5

keeping staff alert and healthy, Mar 2004, 3

limiting mandatory overtime, Mar 2004, 3

and long term care initiatives, Oct 2003, 3

naps during breaks, Mar 2004, 3

screening indicators, Oct 2001, 3

unsafe staffing levels, Mar 2004, 6

Standardized drug concentrations

and the Rule of Six, May 2005, 9-10; Jun 2005, 7-8

Standards

compliance, Jun 2001, 4; Oct 2001, 3, 5; Nov 2001, 2

corresponding to root causes of sentinel events, Aug 2001, 10

development, Aug 2001, 6

environment of care and patient safety, Mar 2002, 2

herbal products and surgery, Jan 2002, 2

long term care, Feb 2002, 1, 3, 9

leadership roles, Feb 2002, 1, 3, 9

patient safety, May 2001, 1, 3, 5

performance improvement and safety, Jul 2002, 2

prevention of treatment delay, Nov 2001, 2

requirements for staff orientation, Jan 2002, 7

resident safety, Feb 2002, 1, 3, 9

review task force, Aug 2001, 6-7

revisions, May 2001, 1, 3; Aug 2001, 6; Oct 2001, 1, 3

safety relevance, May 2004, 3

and sound-alike medication guidelines, Sep 2001, 2

staffing effectiveness, Oct 2001, 1, 3, 5

suicide prevention, May 2002, 2

Standards Link, Sep 2002, 2; Dec 2002, 2; April 2003, 3, 6; Oct 2003, 3; Jan 2004, 3-4; Apr 2004, 3

and LD safety standards, Apr 2004, 3

assessment adequacies, Dec 2002, 2

infection control, Sep 2002, 2

hand washing, Sep 2002, 2

risk reduction strategies, Sep 2002, 2

provision of care, treatment, and services standards, Jan 2004, 3-4

Standards Review Task Force, Oct 2002, 3, 9

Standardizing abbreviations, Jun 2003, 1-2

Storage of blood, Jan 2004, 6

and blood transfusion errors, Jan 2004, 6

Suicide, Aug 2001, 3; Jan 2002, 4; May 2002, 2

and availability of patient information, Jul 2002, 5

and emergency department assessments, Dec 2002, 1

and firearms risk management program, Sep 2002, 8-9

high-risk groups, Jul 2001, 11

prevention, Jun 2001, 5; Jul 2001, 10; Aug 2001, 11; May 2002, 2; Feb 2005, 4, 6

Surgical extraction

marking teeth, Aug 2003, 11

Surgical fires, Oct 2003, 11; Sep. 2004, 13; Oct. 2004, 11; Aug 2005, 13

anesthesia induction, Feb 2005, 5–6

compliance suggestions, Sep. 2004, 13; Aug 2005, 13

Joint Commission requirements, Sep. 2004, 13; Aug 2005, 13

National Patient Safety Goals, Oct. 2004, 11; Feb 2005, 7

prevention, Oct 2003, 11; Oct. 2004, 11

reducing risk of, Sep. 2004, 13; Aug 2005, 13

Surgical services

informed consent guidelines, Mar 2005, 1

Surgical site infections, Oct 2001, 11

antimicrobial prophylaxis, Oct 2001, 11

asepsis and surgical technique, Oct 2001, 11

postoperative incision care, Oct 2001, 11

preoperative preparation of the patient, Oct 2001, 11

surveillance, Oct 2001, 11

Surgical site marking, see also wrong-site surgery, Jan 2003, 4; Sep 2003, 7-9; Mar 2005, 7

Surgical tools

left in patients, Jun 2003, 11

Survey data results, Jun 2003, 1-2, 4

Survey on Patient Safety Culture,Mar 2005, 5–6

Survey process

accreditation participation requirements, Nov 2002, 2

and infection control, Mar 2003, 3

and medication safety, Mar 2003, 3

and patient safety, Dec 2001, 1, 3

emergency management, Apr 2002, 2

evaluation and consultation, Apr 2002, 2

leadership interview, Aug 2002, 2

leadership role in, Aug 2002, 2

link to, Jun 2001, 2; Aug 2001, 3; Oct 2001, 2, 5; Dec 2001, 2, 5; Feb 2002, 2; Apr 2002, 2; Jun 2002, 2; Aug 2002, 2; Mar 2003, 3

National Patient Safety Goals, Jul 2003, 3-4, 10

National Patient Safety Goals, Nov 2002, 2; Mar 2003, 3; Aug 2003, 3-4, 10

nursing leadership interview, Feb 2002, 2

RUS, July 2003, 3-4, 10

systems analysis, Apr 2002, 2

visits to patient care settings, Dec 2001, 2, 5

visits to resident care settings, Jun 2002, 2

System tracers, Feb 2004, 3, 10; Feb 2005, 3

data use, Feb 2004, 3

infection control, Feb 2004, 3

medication management, Feb 2004, 3, 10

System-level patient safety plan, Oct 2003, 9-10

implementation, Oct 2003, 10

Systems analysis, Mar 2003, 7–8; Aug 2003, 5-6; Nov 2003, 7-8; May 2004, 5-6; Jul 2004, 5-6; Oct. 2004, 3-4, 10

assess early and often to avoid unnecessary use of restraint and seclusion, May 2004, 5-6

ensure that float staff and contracted staff are providing safe care, Jul 2004, 5-6

failure mode and effects analysis, Mar 2003, 7–8; Aug 2003, 5-6;

monitoring compliance with National Patient Safety Goals, Nov 2003, 7-8

root cause analysis, Mar 2003, 7–8

strategies for using the infection control priority focus area to improve patient safety, Oct. 2004, 3-4, 10

Task time line for project planning,Mar 2005, 6

Taxonomy, patient safety, Aug 2002, 1, 3

Team training, Mar 2002, 1, 3, 9

error reduction, Mar 2002, 1, 3, 9

Teeth marking, Aug 2003, 7, 11; Sep 2003, 8

Temporary staff, Apr 2005, 6

Ten-fold error, Nov 2004, 2

Texas Medical Association, Apr 2005, 8

Threat analysis,Mar 2005, 4

Time-outs, Nov 2003, 2, 4; Sep 2004, 15; Aug 2005, 15

To Err is Human: Building a Safer Health System, Nov 2001, 6

Tracer methodology, Oct 2003, 1-2, 4; Dec 2003, 1; Feb 2004, 3, 10

and patient safety, Oct 2003, 1-2, 4

tracer activities; Oct 2003, 1-2, 4

Tracers, May 2004, 8

Tracking systems, Feb 2004, 9-10

improvement of, Feb 2004, 9-10

Training of staff, May 2001, 2; May 2002, 4-5

safety improvement, May 2002, 4-5

and sentinel events, May 2001, 2

Transferring patients

in emergency departments, Dec 2002, 3, 9

Transfusion events/errors, Aug 2001, 4; Nov 2001, 5; Jul 2004, 4

Transitional care, Jan 2004, 7-8

and improving patient safety, Jan 2004, 8

and postdischarge adverse events, Jan 2004, 7-8

Transitional care unit, Mar 2004, 9-10

Treatment delay prevention, Nov 2001, 2; Oct 2002, 11

Triennial survey, Jun 2001, 2

and adverse events, Jun 2001, 2

Trinity Mother Frances Health System

and sentinel event reporting, Jul 2005, 5-6

Tropical Storm Allison, Apr 2005, 6

Twin Valley Behavioral Healthcare

case study, Sep 2002, 8-9

firearms risk management, Sep 2002, 8-9

patient suicide reduction, Sep 2002, 8-9

U.S. Department of Health and Human Services

and support of electronic medical records, Jul 2005 1-2, 8

U.S. Pharmacopeia (USP), Oct 2002, 10

Web site, Oct 2002, 10

U.S. Pharmacopeia-National Formulary (USP-NF), Aug 2004, 3-4

compliance with, Aug 2004, 3-4

crosswalk to Joint Commission hospital stan