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Quality Improvement & Patient Safety Section Newsletter, March 2011



circle_arrowThe Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowEditor’s Note - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowEmergency Medicine Action Fund Announced - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowEMPSF 1st Annual Patient Safety Summit - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowIf McDonald’s Ran Your ED - Quality Improvement & Patient Safety Section Newsletter, March 2011, March 2011
circle_arrowQIPS Tips #10 The Handoff - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowThe Healthy Emergency Department – Part 2 - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowFocus On Low Health Literacy - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowSt. Luke’s Hospital – Active Shooter in the ED - Quality Improvement & Patient Safety Section Newsletter, March 2011
circle_arrowQuality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, March 2011

The Chair’s Letter - Quality Improvement & Patient Safety Section Newsletter, March 2011

Drew Fuller, MD, MPH, FACEP
John Hopkins Bayview Medical Center
Baltimore, MD

Safety First ……..How Can We Advance the Agenda? 

Drew FullerWith healthcare reform and regulatory issues rightfully at the top of ACEP’s agenda there is an opportunity for the College and our profession to continue to meet these challenges, as well as to advance one of the greatest priorities in emergency medicine, that of patient safety.  

While our industry strives to place safety and quality amongst our highest priorities, too often real safety improvements are jeopardized by a lack of critical focus or the understandable distraction of competing “quality” and management issues.  Our profession, however, is positioned to help lead the industry in making change and advancing the movement for real improvement in patient safety. 

Recognizing that the healthcare system is failing to show demonstrable improvements in safety and that EDs are by their nature one of the highest risk environments, there is a need for a transformational approach. It is unlikely that we will achieve transformational change without a making a transformation ourselves.  

We need a Safety First perspective integrated into everything we do from education, to research, to clinical and administrative policies and practices to health policy and funding.  In essence, safety must be the firstpriority. It must be purposeful and prospectively designed and built into our processes, policies and practices. 

Now is the time.  As we undergo healthcare reform, our specialty has an opportunity to regroup and rethink how we operate. We have a chance to demand that patient safety be a priority in everything we do. 

What are some possible next steps for setting a Safety First agenda? 

  • Form an ad hoc Safety First Task Force to study the issue and formulate a future strategy?
  • Establish a Patient Safety Committee via a Council Resolution for ongoing strategy, recommendations?
  • Partner with other organizations to form an Emergency Medicine Patient Safety Institute that would commit resources, time and energy for studying critical safety issues and developing broad reaching and long-term solutions?

A transformational approach to advancing patient safety in emergency care will serve our patients, our physicians, and our profession. No other group is as well positioned to lead this charge.

QIPS section members and others can help advance the message that a “Safety First” approach for safety is needed for the specialty.  Help us strategize, join the movement and express your voice locally and nationally.  

Feel free to email me with your thoughts and suggestions.   

Editor’s Note - Quality Improvement & Patient Safety Section Newsletter, March 2011

Richard T. Griffey, MD, MPH, FACEP
Washington University School of Medicine
St. Louis, MO

This has been another busy quarter for the QIPS Section. We partnered with the EM Informatics Section to submit a letter of intent for a joint section grant proposal on “Quality and Safety Implications of Emergency Department Information System Implementation.”  We are continuing to refine our survey of EM departments to assess the current state of resource allocation for ED Patient Safety and Quality officers. In February QIPS sent out a survey to section members regarding benefits you would like to see from QIPS membership in the future – results forthcoming. We plan to use this information as well as other input to improve the section’s website format, focusing on making this a useful and easily navigable resource for our members.  If you have thoughts or suggestions on this please send them to me .


Emergency Medicine Action Fund Announced - Quality Improvement & Patient Safety Section Newsletter, March 2011

ACEP's new grassroots effort aims to influence health care reform’s regulatory implementation. 

With changes in the health care system already underway, a new initiative is looking to positively impact the regulations that will be written and implemented under this sweeping reform. 

The Emergency Medicine Action Fund, launched by ACEP in February, will pool contributions from individual emergency physicians and groups, ACEP Sections of Membership, and anyone else interested in advancing emergency care to provide financial support for advocacy activities in the regulatory arena.     

“This is probably the most important, defining moment for emergency medicine in our lifetime,” said ACEP President Dr. Sandra Schneider. “The decisions that are made now will set the course for us for years to come and we must positively influence the regulatory agenda. This Action Fund will help us do that and create a practice environment we can thrive in.”    

The Emergency Medicine Action Fund will pursue a regulatory agenda that supports emergency physicians and quality emergency care.  For example, evolving practice models and demonstration projects, such as accountable care organizations and bundled payments, are two areas of the Patient Protection and Affordable Care Act where the Action Fund might be able to wield some influence.    

“We need to be out there with the rule writers, working to ensure that emergency medicine’s perspective is valued,” said Dr. Angela Gardner, ACEP Past President who first proposed a national grassroots initiative focused on federal regulatory affairs. “It is critical that we be involved in these decisions regarding the formation of the future of health care delivery. This is our opportunity to be part of it.”    

The following organizations have been invited to designate representatives to the initial Board of Governors – American Academy of Emergency Medicine (AAEM), Association of Academic Chairs of Emergency Medicine (AACEM), American College of Osteopathic Emergency Physicians (ACOEP), Emergency Department Practice Management Association (EDPMA), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM).    

One of the unique features of the Emergency Medicine Action Fund is that multiple Sections can band together to form coalitions that would be eligible to have a seat on the Board of Governors.  Or Sections can organize their individual members for collective representation. The first 10 groups of contributors at $100,000 will be granted seats on the Action Fund’s Board of Governors.     

“We are encouraging Sections, chapters and small to mid-sized groups to combine their resources,” Dr. Schneider said. “This is intended to be an inclusive effort, and everyone’s contributions are needed.”    

The Emergency Medicine Action Fund is modeled on a successful initiative sponsored by CAL/ACEP, CAL/AAEM, EDPMA, and rural emergency physicians in California that has raised several million dollars for  state advocacy since 2004.     

Wes Fields, chair of the California Emergency Medicine Advocacy Fund, said their program doubled the size of the CAL/ACEP advocacy staff, increased the number of lobbyists and consultants, and engaged in legal activities related to physician payment practices.  He has been appointed by Dr. Schneider as the founding chair of the new national Action Fund.     

“I view this as the best form of free speech on behalf of emergency physicians and our patients,” Dr. Fields said. “It is not partisan. It is not political.     

“The rule writers and the policy makers will hear emergency medicine speaking with one voice, with one set of goals, one approach,” he added. “We need wide and deep support, even from those who are not members of the College.”    

CEP America, the nation’s largest emergency medical partnership, will be the inaugural donor to the Emergency Medicine Action Fund, pledging  $100,000.    

Activities planned by the Emergency Medicine Action Fund are intended to enable participants to make contributions that would be tax-deductible business expenses (tax deductibility can be determined only by participants’ tax advisors).   

NEMPAC, the National Emergency Medicine Political Action Committee of the ACEP, gives contributions to candidates who have listened to the needs of emergency medicine and made a positive change. However, NEMPAC may be used only to support candidates.    

The Action Fund can enhance regulatory advocacy with policy makers to ensure emergency physicians receive fair payment for their services. It can also fund numerous meetings with regulators to help guarantee that patients receive the best care, and provide funding for studies to demonstrate the value of emergency medicine.    

“With the new Congressional session upon us, it is as important as ever to be active on both the legislative and regulatory fronts,” Dr. Schneider said. “We will depend on all of these funds to make our case. This will be the year we ask everyone to dig a little deeper. In these challenging times, we need contributions to both the Action Fund and NEMPAC.”    

Find out more about the Emergency Medicine Action Fund at  

 How is the Emergency Medicine Action Fund Different from NEMPAC? 

Both are valuable tools that need our continued support, but the Emergency Medicine Action Fund serves a different purpose than NEMPAC.   



EM Action Fund 

Gives campaign contributions to Congressional candidates 



Funds meetings with regulators and policy makers   



Enhances emergency medicine advocacy efforts 




EMPSF 1st Annual Patient Safety Summit - Quality Improvement & Patient Safety Section Newsletter, March 2011

Patient Safety in Emergency Care: Excellence in Outcomes
May 5-6, 2011
Four Seasons Hotel, Las Vegas, Nevada

This important conference will bring together a distinguished group of key stakeholders and thought leaders devoted to solving the patient safety challenges associated with providing emergency care in the pre-hospital and Emergency Department (ED) setting. Attendees will include emergency medicine providers, nursing, administrators, EMS, pharmacy, risk management and patient safety officers and researchers.  

This two-day event provides a forum for participants to learn from experts in the field of emergency care patient safety. The objective of the conference is to provide an opportunity for individuals to collaborate and network together to hear about patient safety solutions in emergency care and discuss ways and means to address outstanding challenges. The Summit Agenda offers an outstanding list of topics for discussion, impressive list of presenters with significant expertise, and an intimate environment to network with your peers. Educational sessions will focus on best practices and evidence based solutions that have been applied and demonstrated to be successful in various ED’s across the country.  

Complete information, registration and link for hotel reservations are available on the EMPSF website at  If you have questions, please contact Dianne Vass, Executive Director of EMPSF at 916.357.6723 or via email at

If McDonald’s Ran Your ED - Quality Improvement & Patient Safety Section Newsletter, March 2011, March 2011

Dickson Cheung, MD, MBA, MPH
Sky Ridge Medical Center
Lone Tree, CO

Dr. Dickson CheungThe medical quality and safety community is fond of business analogies, particularly those from the aviation and service industries. Why Hospitals Should Fly is a national best seller. The CEO at my local hospital was so enamored with If Disney Ran Your Hospital, that it became required reading for the medical executive committee. The book, however, that I want to read hasn't been written yet. Because I have learned so much about operations from the restaurant business it should be called If McDonalds Ran Your ED. Hear me out. 

The whole intake process of the ED (i.e. how we receive patients) is now being re-examined. There are two restaurant practices that we should consider. First, we should allow patients to make elective “reservations.” Maybe not such a good idea for chest pain patients, but it may be a nice option for patients with wound checks, suture removals, or a second dose of IV antibiotics. Ever try the on-line reservation system I’d like to see the website You could even pre-register patients. It may even help level out demand and workload. 

Second, for those patients we are unable to see right away after triage, we should hand out pagers similar to the ones used at the Cheesecake Factory. Maybe even attach a pulse oximeter and a text messaging system to it. It'll make it easier to recheck vital signs.  Later, we could use the same pagers for patient’s families who go out to make phone calls, go to the bathroom or eat at the cafeteria. At select Johnny Rockets, patrons are allowed to order their meals via a tableside kiosk. Sort of like Amazon meets Applebees. Who really needs a waiter? Yes, it may add to the experience at a three star Michelin restaurant. But at the Claim Jumper with screaming, hungry kids, I just want my food NOW. 

Two ACEP conferences ago, a close group of work colleagues and I had dinner at Boston’s Legal Sea Foods inside the Prudential Center. As we gave our orders, the waiter busily tapped into a device that resembled a PDA. Unfortunately for my friend, his first selection was sold out. “How did you know that?” we inquired. “My Wi-Fi enabled handheld,” he proudly replied. Wouldn’t it be great to be able to write your orders from the tableside (I mean, bedside)? We could discover medication allergies as we ordered antibiotics in real time. Or that our PYXIS was out of Zosyn®. I know some lucky EDs already have CPOE but what I really want is a cool app on my Android (sorry, I’m not an iPhone user). 

My family had dinner at Bubba Gump last week (see photo) before we went to the Denver Parade of Lights which is fast becoming one of our family traditions. Besides the array of shrimp dish choices, the most impressive part of the restaurant was its signaling system to flag an order. Atop each table are two signs. If you want the waiter to stop, you simply flip to “Stop Forrest Stop!” After the request is taken, you flip back to “Run Forrest Run!” Imagine if we had a patient-controlled signaling system beyond the ‘ol call button. All it would really take is a remote controlled sign outside the room door: “Need pain meds”, “Need blanket”, “Need bathroom”, “Done oral contrast.”   

What was truly remarkable, however, was the tenacity of the waiters. Not only was your assigned waiter servicing your table, but all the waiters within eyesight. We were so impressed with the response times that we impishly made fake requests just to test the system. Team waitering is not exactly unique to Bubba Gump. In fact, the first time I heard the term coined was at White Chocolate Grill where they warned us upfront that many servers would be waiting on us that visit. Not surprisingly, the efficient night staff where I work has a similar practice. Although there is an assigned nurse for each patient, all the nurses and techs pitch in for orders and discharges. 

Tired of running around the ED looking for your colleagues? Annoyed by the overhead pages that are piped into every patient room? Ever wonder why we don’t have a more effective communication system? I’ve seen and used Spectralink phones, walkie-talkies and Vocera badges. None of them work as perfectly as the cordless, hands-free system that I recently saw used at Hacienda Colorado. The place is hopping. And noisy! Hostesses and waiters all wear these ear buds and headsets to communicate with each other discreetly. Works better than yelling across the room. SWAT does it. Pilots do it. It is time we consider trying it. 

Some generic restaurant practices are also worth emulating. If you order coffee, lemonade, iced tea or just water, restaurants now often just leave the entire carafe. It cuts down on the wasted time and effort to pour each cup, i.e. the flagging, the fetching, the filling. Now I know this is controversial but imagine delivering pain medications in the same way via a Patient Controlled Analgesia pump. We could set the dose, the frequency and maximum number of requests. Patients then don’t need to call, secretaries don’t need to page, nurses don’t need to dispense and deliver the dilaudid. Not to mention then having to find another nurse to “waste” the remaining 0.5 mg (another pet peeve of mine, why don’t they make them in 0.5 mg increments?). 

Also, do you ever notice how the bread is already made when you arrive to your table? Same with the butter in those cute little shapes, the water glasses, and the sauces that go with each dish? Why don’t we do that? No, we make everything de novo on demand. If hospitals ran restaurants, we would start making the risotto when someone ordered it. It is the better way, of course. After all, today may be different than ALL the days preceding it when we spike and hang 50-100 IV bags of normal saline a day. Instead, let's take the precious 5 minutes to prepare each bag after a patient arrives bleeding out. I know there are security and billing issues but there is no doubt we could find a better way. Bundling central line sets with drapes, gowns, facemasks and extra chlorhexadine scrubs is a good start. And at least now we have pre- packaged saline flushes. But we need to do more. This isn’t rocket science! 

I am sucker for the prix fixe. Whether it is the seven-course Degustation at Emeril’s or the #7 meal at McDonald’s, I want the whole enchilada. We need to learn how to better bundle and standardize our orders. I have never seen a patient with isolated BMP-deficiency. Instead, I work up 75 year olds with midepigastric pain requiring a CBC, CMP, lipase, troponin and an EKG for starters. Not to mention an IV, pain and anti-nausea medications. So why are we a la carting when it makes us vulnerable to incomplete orders and inconsistent practice? Some will argue that we may occasionally order an unnecessary test. I remember a time in residency at one of the hospitals where I had to order all electrolytes individually, i.e. Na, K, Mg. But how many of you order a BMP when all you want is the creatinine without blinking an eye? Did you really want the chloride?  But we don't seem to sweat it and neither should we. On my last tour of the laboratory, I found out that it is easier for the analyzer to simultaneously run entire panels of tests. The amount of reagent used in each test is on the order of picoliters and costs pennies. So the real “waste” in the system is in finding the samples, rerunning tests, and the man hours required to keep track of all the add-ons. Now, there is the legitimate argument of “cost” vs “charges” which we won’t get into here but if the healthcare system is truly interested in value-based purchasing, we will start prix fixing orders based on panels which we started doing with the CBC, CMP, CSF panels, etc. It just needs to be taken a few steps further. Let’s start by organizing our system by “products”, e.g. the major unknown overdose and save our brain cells for decisions that require them. 

Finally, when the visit doesn’t quite work out as hope for… we should take a lesson from restaurants on service recovery. There is the free dessert (sometimes, even the whole meal!), or a coupon for the next visit. When we fail to live up to our own standards, can’t we at least give out a voucher for free coffee at the cafeteria, or free valet parking in the lot? 

OK, I eat out too much. But seriously, there is much to learn from the restaurant business.  And let’s be honest.  Our job sometimes resembles more maitre d’ than physician.


QIPS Tips #10 The Handoff - Quality Improvement & Patient Safety Section Newsletter, March 2011

Shari Welch, MD, FACEP
Intermountain Institute for Health Care Delivery Research
Salt Lake City, UT

Shari WelchAccording to the Joint Commission the number one cause of sentinel events in hospitals is communication (or lack thereof). The most dangerous point in a patient’s ED journey is the hand-off and transition of care. This has been well recognized and yet most ED hand-offs are unstructured, with little or no documentation for this high risk process. Emergency departments are susceptible treatment delays and in 84% of the time these delays thought to be due to miscommunication.  In 2006 the Joint Commission crafted National Patient Safety Goal 2E to address continuum of care communication issues. To date there are few established standards and a lack of supporting literature in the area. 

In an important 2004 article by Patterson in the International Journal for Quality in Health Care, the hand-off strategies of high risk organizations were studied.  They looked at NASA Johnson Space Center, Canadian nuclear power plants, a railroad dispatch center in the US and a Toronto ambulance dispatch center. They identified strategies that proved effective in transition communication. All communications were verbal and in most cases face to face.  The most crucial finding was that the question and answer part of the hand-off uncovered an important finding in up to a third of hand-offs that impacted performance a third of the time. All hand-offs were standardized, even to the order in which information was exchanged.  “At a glance” visual displays were effective adjuncts to the transition process. 

From a risk management standpoint this is an area that warrants improvement efforts.  In a study of closed claims from four insurers, 24% of malpractice claims were attributed to faulty hand-off communication.  This is leading to a renewed interest in formal team training and communication training for the ED. There are now myriad mnemonic based strategies for hand-offs.  For example the 5-Ps, I PASS the BATON, HANDOFF, and SIGN OUT, to name a few of the more popular. These and several other hospital-based handoff templates include a number of data elements that may not be relevant to ED practice or have unnatural information flows that could decrease efficiency and be impractical to implement.  That said, the hand-off process should be clearly articulated and understood, with standardization and rigorous adherence to protocol. 

There are a few recognized strategies that can be employed for hand-off communication to decrease the risk of adverse outcomes and they are briefly outlined below.   


  1. Bedside face to face sign between providers
  2. Simple at a glance data presentation
  3. Clear articulation of accountability and timing of transfer
  4. Encourage questions
  5. Focus on changes in patient’s potential for change in condition
  6. Minimize hand-offs


The Healthy Emergency Department – Part 2 - Quality Improvement & Patient Safety Section Newsletter, March 2011

Mark T. Fleming and Pat Croskerry 

Continuing our series, a portion of Chapter 7 – “The Healthy Emergency Department” by Laura Pimentel is excerpted with permission from Croskerry, P., Cosby, K.S., Schenkel, S.M., and Wears, R.L, Patient Safety in Emergency Medicine. Philadelphia: Lippincott Williams and Wilkins, 2009.  


A healthy ED is operationally intelligent. Operations are the art and science of accomplishing the daily mission of caring for emergency patients. Important operational components are patient flow, ancillary support, policies, procedures, supplies, and equipment. The American College of Emergency Physicians (14) has published guidelines delineating the minimum infrastructure necessary for appropriate emergency care. The guidelines include lists of recommended supplies, equipment, and drugs. 

In addition to infrastructure, smooth ED operations require appropriately qualified and available consultants and admitting physicians. This is not only an operational consideration for every individual ED, but an important policy question as hospitals struggle with decreasing access to necessary specialists, well-developed transfer and referral patterns must be developed to ensure expeditious care for all patients.  

The number and type of support staff contribute considerably to the intelligent function of the ED. In all but very low volume EDs, ideal numbers of nursing support technicians, secretaries, and transporters are necessary for efficiency. The operational principle is that physicians, mid-level providers, and nurses should spend time performing those functions that require their unique training and expertise. Clerical, transport, stocking, and other important but unskilled tasks should be performed by support personnel.  

Emergency department design is an important prerequisite to operational efficiency. A very important concept for design success is involvement of the physicians and clinical staff during planning (16). Understanding that form follows function, a healthy ED design considers each service line: major resuscitation, trauma, major medical, pediatrics, fast track, and observation services. The incorporation of any or all of these service lines depends upon volume, patient population, and hospital services. The design should reflect human factors that support the work flow (17). Each treatment room should be directly visible from the supporting nursing station. In higher volume departments, consideration should be given to incorporating diagnostic technology into the design. Digital imaging, computed tomography, and stat lab services are common considerations. 

When considering ideal ED operations today, one must consider incorporation of cutting-edge technology. Electronic medical records are increasingly implemented in the emergency setting. Integrated systems have been designed that incorporate most or all of the critical ED functions: triage, registration, patient tracking, physician order entry, physician and nursing documentation, and discharge instructions, including prescriptions. Although electronic medical records are a major capital expense and an operational paradigm shift, recent literature suggests great potential for operational and patient care improvements (18-21). Beyond these benefits, an electronic information system generates data and reports. Accurate data is essential for meaningful quality improvement. A healthy ED evolves through data-driven change.  

Communication must be thoughtfully considered for safe ED function. In physically large departments, technology optimizes rapid communication. Key personnel are immediately accessible by utilizing in-house cordless phones. Text messaging may provide ready means of communicating critical lab values or wet readings of imaging studies. Fax communication is another technological solution to conveying information between physicians or departments. The communication goal is rapid transmission of critical clinical information without excessive or unnecessary interruption.  

Another aspect important for healthy operations is a robust process for handoff communication between and among physicians and staff. Important handoffs occur when physicians and nurses change shifts and when patient care is transferred from the ED to a consultant or inpatient unit. The Institute for Healthcare Improvement recommends the Situation-Background-Assessment-Recommendation (SBAR) technique for communication between members of the health care team (22). This framework provides structure to handoff conversations that minimize the risk of omitting important information. When emergency physicians sign out to one another or to admitting physicians, direct communication is important so that questions can be asked and answered.  

An operationally healthy ED places emphasis on early physician evaluation of al patients. In today’s challenging environment of hospital overcrowding, this requires specific operational attention. A couple of strategies are recommended to facilitate this goal. Accelerated nursing triage expedites patients to treatment rooms and prevents the triage process from becoming a bottleneck (23). Patients should be immediately directed to a treatment area for early physician evaluation (24). Another successful strategy is physician triage of patients during busy hours or when all treatment beds are full (25-27). Improved efficiency, patient satisfaction, and outcomes are the operational benefits of expediting the arrival-to-physician evaluation process. 


Financial solvency is necessary for a well-functioning ED. Three major budgets drive the operation of most departments. These include the operational budget, capital budget, and physician services. The first two are managed by the hospital. Physician services may be as well if the hospital employs the physicians. More commonly, a physician group contracts with the hospital and manages its finances with or without a subsidy from the hospital. 

When evaluating the operational budget, most hospitals calculate the cost per unit or the number of dollars spent per ED patient. This is balanced by the revenue per unit. The payer mix of each individual department will affect the balance and often determine the solvency of the operational budget. A department with a poor payer mix may still function in a healthy fashion if the hospital subsidizes the cost. It is unusually a smart financial decision. Revenue from hospital admissions from the ED often compensates for the operational deficit. 

A healthy ED will have an adequate capital budget. This is important for departments to maintain equipment for proper operations and new equipment as technology evolves. Each hospital administration annually weighs the capital needs and requests of the ED against those of other departments.

Maintaining financial solvency is increasingly challenging for emergency physician groups.  

Reimbursement varies with the payer mix and state insurance law. The cost of liability coverage is a fixed expense that represents a growing percentage of many groups’ budgets. State policy influences the likelihood of physician solvency by governing tort and reimbursement law. Many physician groups are subsidized by the hospital in order to recruit quality physicians and maintain adequate staffing patterns. Regardless of the revenue source, a healthy ED is staffed by fairly compensated physicians working in a financially stable group. 


Finally, and perhaps most importantly, a healthy ED is relational. Physicians are cohesive and supportive within the group; they communicate professionally and cordially to the hospital medical staff. Nurses relate well to one another and the physician group. All physicians and staff relate to patients in a compassionate and nonjudgmental fashion. When healthy relationships exist in the ED, departmental leaders maintain open communication with hospital administrators and clinical colleagues. Bruce Janiak (28), former president of the American College of Emergency Physicians notes, “In every consultation I have made in which the ED group contract was in jeopardy, the administrator reported minimal or no interactions with the ED leader.” When asked to identify the most important quality for success in health care leadership by a class of physician executives, Joseph Stewart, former CEO of Butler Health Systems in Pennsylvania unhesitatingly answered, “Relationships, it is all about relationships.” 


The first step toward developing a healthy ED is to develop a vision of the way emergency medicine should be practiced. The second is to analyze the way it is practiced within a physician group or department. The third step is to generate a plan for transitioning from the way it is to the way it ought to be. A robust department begins with principled physician and nursing leadership. Effective staffing from a qualitative and quantitative perspective is crucial. Outstanding operations with the goal of early physician evaluation of all ED patients should be the goal of leaders, physicians, and staff. Operations are assisted by well-designed space and thoughtful technology. Financial solvency and positive relationships complete the picture of a strong and vigorous ED. This is the way emergency medicine should be and, hopefully, the way it will be. 


  • Outstanding leadership is the most important component of a healthy emergency department. The chief executive officer and senior leaders shape the culture; physician and nursing leaders provide vision and operational direction.
  • A healthy emergency department:
    • is consistently staffed with well-trained professionals sufficient to meet the demands for patient flow and quality care.
    • is operationally intelligent: appropriately equipped, staffed, and designed to support work and flow
    • is financially stable, with adequate operational and capital budgets and fairly compensated staff
    • thrives on stable and supportive relationships between clinical staff and hospital administrators
  • Leaders should have a vision for emergency medicine to build a robust and healthy organization.






Focus On Low Health Literacy - Quality Improvement & Patient Safety Section Newsletter, March 2011

Richard T. Griffey, MD, MPH, FACEP
Washington University School of Medicine
St. Louis, MO

Low health literacy (LHL) is defined by the National Institutes of Health as “the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness.”[1] Low health literacy is recognized as a major determinant of health outcomes, affecting nearly half of all American adults and estimated by the Institute of Medicine to cost $73 billion annually. [2] According to the American Medical Association, poor health literacy is "a stronger predictor of a person's health than age, income, employment status, education level, and race." [3] It is reported that 21% of Americans cannot understand newspaper headlines and 48% of patients cannot make sense of basic bar graph.  

Adequate health literacy is critical in all aspects of health care, including the ability to read prescriptions, to understand and provide informed consent as well as understanding verbal information given by health providers. Inadequate health literacy is associated with poorer health status, less knowledge about chronic disease self-management, and lower rates of medication adherence. [4] The elderly, minorities, those with low-socioeconomic status, patients with limited English proficiency, and the mentally or physically impaired are among those most likely to be affected. [5] Low health literacy is also correlated with higher rates of acute health care utilization in patients with chronic diseases. [6] The mechanisms by which low health literacy affects health are complex and likely multiple.  

Health literacy is increasingly recognized by many major health care organizations as an area of priority for research and policy initiatives. Nine of the Joint Commission’s National Patient Safety Goals relate to health literacy and TJC has released two recent reports on health literacy, signaling increased attention to this topic as part of accreditation. Despite this increasing attention, health literacy is still an unknown entity to many providers and remains understudied.  

Recently a nice systematic review summarized the literature on health literacy in the ED   (Boylston Herndon, PhD, Michelle Chaney, MS, Donna Carden. Health Literacy and Emergency Department Outcomes: A Systematic Review. Article in Press - doi:10.1016/j.annemergmed.2010.08.035). Collectively, approximately 40% of ED patients were found to have limited health literacy, with estimates ranging from as low as 10.5% in the case of caregivers for pediatric ED patients to as high as 88% of adult ED patients over 60 years old. In addition 25-33% of patients lacked numeracy skills for basic interpretation of health information. Patients with limited health literacy appear to have an increased risk of ED utilization and increased costs. Printed ED materials are often written at levels surpassing the literacy skills of a large proportion of ED patients.  

This is perhaps not new information for many ED providers, who may appreciate some of the repercussions of low health literacy such as return visits and non-adherence with medication. Papers in the ED literature nearly 20 years ago document the high reading level required for many ED discharge forms or patients’ lack of understanding of discharge instructions.  Still, doctors presume that patients understand what is being said or written. Patients with low literacy feel intimidated, ashamed, confused, embarrassed and fearful when they are unable to understand or comprehend what is being communicated and consequently may not ask questions. 

Unfortunately there are few examples of successful interventions for low health literacy. Apart from asking questions to screen for low heatlh literacy, providing effective communication is obviously essential in bridging the gap for these patients. Using plain language and avoiding jargon and medicalese in discharge instructions is one way to improve communication. When is the last time you reviewed your own aftercare instruction sheets or your standard discharge forms? The average American reads at an 8th grade level but in low health literacy patients these may need to be written at reading levels as low as the 4th grade. In addition for some conditions it may be helpful to use visual aids beyond text. Tools embedded in Microsoft Word will scan your discharge instructions to provide an estimate for the grade level at which it is written. Other proposed strategies include asking the patient to “teach back” or explain back to the provider the information communicated at discharge, especially relating to the problem(s) identified during their visit, any medication instructions and follow-up instructions. The AHRQ along with others promotes this as the “Ask Me Three” campaign. For additional suggestions and to view a telling AMA video on health literacy, go to:  You can also check the AHRQ website for more information and a toolkit on the AskMeThree program.  


  1. Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, Parker RM, eds. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. NLM Publication No. CBM 2000-1. Bethesda, MD: National Institutes of Health, US Department of Health and Human Services; 2000.
  2. (Report on the Council of Scientific Affairs, Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association, JAMA, Feb 10, 1999).
  3. National Academy on an Aging Society Fact Sheet. 
  4. Institute of Medicine. Health Literacy: A Prescription to End Confusion (2004).
  5. National Network of Libraries of Medicine. 
  6. Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005;172(8):980-986.


St. Luke’s Hospital – Active Shooter in the ED - Quality Improvement & Patient Safety Section Newsletter, March 2011

Special contribution from the Tactical EM Section 

Preston Fedor, MD
Glenn A. Bollard, MD, FACEP 

The first thing we heard was the gunshots.  We would later learn that a patient's estranged husband had shot his way through our security guard and our receptionist.  …….As more shots rang out, we could tell they were getting closer.……. What we feared the most was confirmed by blood soaked people running toward us in the hallway.  Before the alert came through the overhead loudspeakers, staff and patients were already running.……. Running into open rooms…..out the ambulance bay doors…..into radiology…..they were running everywhere…….. We had only seconds to push gurneys and wheelchairs bearing patients into lockable spaces as we tried desperately to comprehend what was happening.……Then he appeared…… the lone gunman…… in contrast to all around him, he was resolute and confident.  He marched steadily toward the room where his ex-wife and son were trying to hide…… He fired indiscriminately at the innocent bystanders he encountered along the way……..He found what he was looking for and took his ex-wife,…his terrified son…..and a nurse hostage. 

What followed was a 2 hour standoff during which the Allentown Police Department’s Emergency Response Team (ERT) attempted to negotiate with the barricaded gunman.  Ultimately the hostages were rescued unharmed after a fatal shootout took place between the ERT and the perpetrator.  In all, 13 staff members and 2 patients were killed during the initial 5 minute Emergency Department (ED) rampage.  Many more were injured, some of them seriously.

Fortunately, this was just an elaborate active shooter drill held during the summer of 2010 in the Emergency Department of St. Luke’s Hospital which is located in Allentown, PA.  Unfortunately, nightmarish scenarios such as these are becoming more commonplace in EDs all across the country.  All too frequently, we hear about someone walking into a healthcare setting with a firearm, or of a patient brandishing a weapon and attacking staff.  Scientific studies corroborate the impression that workplace violence has been increasing in a variety of settings that are normally associated with the provision of healthcare and social services.   

The following Websites contain up-to-date research data relevant to this topic; The U.S. Department of Justice (DOJ) at, The U.S. Bureau of Labor Statistics (BLS) at, and The National Institute for Occupational Safety and Health (NIOSH) at

Given the fact that workplace violence in healthcare settings is on the rise how can a healthcare system decrease the likelihood of experiencing such a tragedy?  What policies and procedures might mitigate at least some of the carnage associated with such events?  What do local Police Departments and Sheriffs need to know about the layout of all the healthcare facilities within their jurisdiction?  What are the components of a viable action plan for each of those settings (Hospitals, Urgent Cares, Nursing Homes, Drug and Alcohol Treatment Centers, etc.)?  

These questions, and the very real specter of violence in the ED workplace, drove St. Luke's Hospital to conduct this multiagency drill.  Dr. Fedor is a senior Emergency Medicine Resident at St. Luke’s Hospital.  He was a member of the hospital Emergency Management Committee which approved, and helped to implement, the active shooter exercise.  The hospital is a part of the larger St. Luke’s Hospital & Health Network.  They provide services through 158 sites and draw patients from 8 Counties in PA and Warren County in NJ.  Their AOA and ACGME approved EM Residency programs are affiliated with 4 different hospitals.  St. Luke’s Hospital in Allentown is one of their mid-sized facilities and they see approximately 45,000 patients per year in the ED.  An expansion project to increase the ED by approximately 25% had been completed just prior to the exercise.  This allowed the older portion to be used in the scenario without adversely affecting the delivery of routine patient care.  Patient and family member roles were played by actors wearing moulage.  Physicians, nurses, and ED ancillary staff played themselves and were asked to spontaneously respond to what they thought was going on.  The law enforcement officers (LEOs) of the ERT were not told that this was a drill until they reached the staging area.  They were paged and told where to assemble just like they would have in a real emergency.  The only information they received during the briefing was that it was an active shooter drill and that they were to conduct the Operation as if it were a normal call out.  They donned protective equipment, removed all their weapons and were given Simunition guns.  Role players who could end up in the line of fire were also fitted with protective gear.    

The goal of the exercise was three fold: 1) to better prepare the staff and health system for this dynamic situation; 2) to familiarize local law enforcement and the ERT with the challenges of operating in the Emergency Department; and 3) to open lines of communication and facilitate an ongoing collaboration between the stakeholders after the exercise was over. 

A full scale drill of this kind, set in an actual ED, is rarely done.  As such, many lessons were learned both on the healthcare and the law enforcement side.  Some of the major findings are listed below. 

ED Lessons:  

  1. A pre-determined emergency code announced over the PA was an essential warning mechanism.  It granted staff and patients additional time to either evacuate or hide.
  2. Despite perceiving that there might be a potentially deadly situation (hearing shots fired) and hearing the warning announced over the PA system, some staff remained curious and actually moved towards the shooting.  Some hid but rendered their concealment ineffective because they kept peeking to see what was going on.  Such behaviors accounted for a number of the ED staff member deaths.
  3. It was difficult to convince doctors and nurses to leave their patient’s sides, even to save their own lives.
  4. An all-clear signal must be implemented, as some staff remained hidden longer than necessary.
  5. Patient comfort measures such as reflective windows and blinds impede law enforcement’s ability to do reconnaissance from the outside.
  6. A mechanism to divert incoming ambulance traffic and walk-in patients must be established and drilled. 

LE Lessons:  

  1. The ED is a unique physical space for which significant pre-planning is necessary.
  2. A Blueprint of a floor plan is no substitute for a walk-through or drill in such a complex environment.
  3. Having a hospital reference book detailing floor plans, locations of oxygen and water shutoff valves, hazards, chemicals, and relevant components of the physical plant that could be given to LE during such a crisis would be very helpful.
  4. Common radio frequencies between LE, hospital incident command, and security should be arranged in advance.
  5. Emergency Department staff should remain available to manage alarming ventilators, monitors, and beds.  Alternately, a member of the TEMS component can be familiarized with these issues.  It was very distracting to LE and to the suspect during crisis negotiations to have various alarms going off, and LE didn’t know how to silence them.
  6. It is not ideal to use incendiary devices in an oxygen-rich environment or to use gas in an area where the ventilation systems are designed to re-circulate the air.

For further details on the active shooter scenario please contact Dr. Fedor .  In July, 2011 Dr. Fedor will begin a Government Emergency Medicine Security Services (GEMSS) Fellowship at the University of Texas Southwestern Medical Center in Dallas, Texas.  Therefore, after June 1, 2011 please contact him through the ACEP/TEM Section Staff Liaison Denise Fechner.  

Quality and Safety Articles - Quality Improvement & Patient Safety Section Newsletter, March 2011

Helmut Meisl, MD, FACEP
Quality Improvement Director
Good Samaritan Hospital
San Jose, California

meislQuality and Safety Articles
Here is a list of recent articles for your interest. These are compiled by AHRQ PSNet at (

Incidence and types of non-ideal care events in an emergency department.

Hall KK, Schenkel SM, Hirshon JM, Xiao Y, Noskin GA. Qual Saf Health Care. 2010 Aug 19; [Epub ahead of print].

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality?: Evidence from survey data.
Helmchen LA, Richards MR, McDonald TB. Med Care. 2010 Sep 8; [Epub ahead of print].

Rethinking rapid response teams.
Litvak E, Pronovost PJ. JAMA. 2010;304:1375-1376.

Automated detection of harm in healthcare with information technology: a systematic review.
Govindan M, Van Citters AD, Nelson EC, Kelly-Cummings J, Suresh G. Qual Saf Health Care. 2010 Jul 29; [Epub ahead of print].

Understanding whistleblowing: qualitative insights from nurse whistleblowers.
Jackson D, Peters K, Andrew S, et al. J Adv Nurs. 2010;66:2194–2201. 

Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.

Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304:1198-1203.

Experience with family activation of rapid response teams.
Bogert S, Ferrell C, Rutledge DN. Medsurg Nurs. 2010;19:215-222.

Assessing teamwork attitudes in healthcare: development of the TeamSTEPPS teamwork attitudes questionnaire.
Baker DP, Amodeo AM, Krokos KJ, Slonim A, Herrera H. Qual Saf Health Care. 2010 Aug 10; [Epub ahead of print].

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

What’s past is prologue: organizational learning from a serious patient injury.
Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

Prevalence of adverse events in pediatric intensive care units in the United States.
Agarwal S, Classen D, Larsen G, et al. Pediatr Crit Care Med. 2010;11:568-578.

Clinical handover of patients arriving by ambulance to the emergency department: a literature review.
Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Int Emerg Nurs. 2010;18:210-220.

Viewing health care delivery as science: challenges, benefits, and policy implications.
Pronovost PJ, Goeschel CA. Health Serv Res. 2010;45:1508-1522.

Clinical handover incident reporting in one UK general hospital.

Pezzolesi C, Schifano F, Pickles J, et al. Int J Qual Health Care. 2010;22:396-401.

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010 Aug 25; [Epub ahead of print].

Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service.
Climente-Martí M, García-Mañón ER, Artero-Mora AA, Jiménez-Torres NV. Ann Pharmacother. 2010 Oct 5; [Epub ahead of print].

Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

Increasing patient safety and surgical team communication by using a count/time out board.
Edel EM. AORN J. 2010;92:420-424.

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

Emotional influences in patient safety.
Croskerry P, Abbass A, Wu AW. J Patient Saf. 2010 Sept 30; [Epub ahead of print].

The anatomy of health care team training and the state of practice: a critical review.
Weaver SJ, Lyons R, Diazgranados D, et al. Acad Med. 2010 Sep 21; [Epub ahead of print].

What is the safety of nonemergent operative procedures performed at night?

Turrentine FE, Wang H, Young JS, Calland JF. J Trauma. 2010;69:313-319.

Validity of selected patient safety indicators: opportunities and concerns.
Kaafarani HM, Borzecki AM, Itani KM, et al. J Am Coll Surg. 2010 Sept 22; [Epub ahead of print].

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.
Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

The Preventable Harm Index: an effective motivator to facilitate the drive to zero.
Brilli RJ, McClead RE Jr, Davis T, Stoverock L, Rayburn A, Berry JC. J Pediatr. 2010;157:681-683.

Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?
Frey B, Schwappach D. Curr Opin Crit Care. 2010 Oct 7; [Epub ahead of print].

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2010 Oct 15; [Epub ahead of print].

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.
Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.

How are medication errors defined? A systematic literature review of definitions and characteristics.
Lisby M, Nielsen LP, Brock B, Mainz J. Int J Qual Health Care. 2010 Oct 17; [Epub ahead of print].

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.
Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Drug Saf. 2010;33:1027-1044.

Rapid response systems: from implementation to evidence base.
Sarani B, Scott S. Jt Comm J Qual Patient Saf. 2010;36:514-517.

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-636.

Measuring the cost of hospital adverse patient safety events.
Carey K, Stefos T. Health Econ. 2010 Oct 20; [Epub ahead of print].

Literature review: do rapid response systems reduce the incidence of major adverse events in the deteriorating ward patient?
Massey D, Aitken LM, Chaboyer W. J Clin Nurs. 2010 Oct 28; [Epub ahead of print].

Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

Effect of emergency medicine pharmacists on medication-error reporting in an emergency department.
Weant KA, Humphries RL, Hite K, Armitstead JA. Am J Health Syst Pharm. 2010;67:1851-1855.

Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 27 Oct 2010; [Epub ahead of print].

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.
Coverdill JE, Carbonell AM, Fryer J, et al. Acad Med. 2010;85:S72-S75.

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.
Wessell AM, Litvin C, Jenkins RG, Nietert PJ, Nemeth LS, Ornstein SM. Qual Saf Health Care. 2010;19:e21. 

Effect of a comprehensive surgical safety system on patient outcomes.

de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. N Engl J Med. 2010;363:1928-1937.

Patient safety begins with proper planning: a quantitative method to improve hospital design.
Birnbach DJ, Nevo I, Scheinman SR, Fitzpatrick M, Shekhter I, Lombard JL. Qual Saf Health Care. 2010;19:462-465.

Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions.
Mills PR, McGuffie AC. Emerg Med J. 2010;27:911-915.

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

Patient education to prevent falls among older hospital inpatients: a randomized controlled trial.
Haines TP, Hill A-M, Hill KD, et al. Arch Intern Med. 2010 Nov 22; [Epub ahead of print].

Medical malpractice liability in the age of electronic health records.
Mangalmurti SS, Murtagh L, Mello MM. N Engl J Med. 2010;363:2060-2067.

How to use an article about quality improvement.
Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Needham DM. JAMA. 2010;304:2279-2287.

How do black-serving hospitals perform on patient safety indicators?: Implications for national public reporting and pay-for-performance.
Ly DP, Lopez L, Isaac T, Jha AK. Med Care. 2010;48:1133-1137.

Going blank: factors contributing to interruptions to nurses' work and related outcomes.
Hall LM, Ferguson-Paré M, Peter E, et al. J Nurs Manag. 2010;18:1040-1047.

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

Nature, causes and consequences of unintended events in surgical units.
van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.
De Winter S, Spriet I, Indevuyst C, et al. Qual Saf Health Care. 2010;19:371-375.

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2010 Oct 28; [Epub ahead of print].

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.
Drolet BC, Spalluto LB, Fischer SA. N Engl J Med. 2010;363:e34.

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.
Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010 Nov 30; [Epub ahead of print].

Electronic health records and adverse drug events after patient transfer.
Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.

Infection preventionist checklist to improve culture and reduce central line–associated bloodstream infections.
Goeschel CA, Holzmueller CG, Cosgrove SE, Ristaino P, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:571-575.

Slowing down to stay out of trouble in the operating room: remaining attentive in automaticity.
Moulton CA, Regehr G, Lingard L, Merritt C, MacRae H. Acad Med. 2010;85:1571-1577.

Possible solutions for barriers in incident reporting by residents.
Martowirono K, Jansma JD, Van Luijk SJ, Wagner C, Bijnen AB. J Eval Clin Pract. 2010 Oct 25; [Epub ahead of print].

Nighttime and weekend medication error rates in an inpatient pediatric population.
Miller AD, Piro CC, Rudisill CN, Bookstaver PB, Bair JD, Bennett CL. Ann Pharmacother. 2010;44:1739-1746.

NPSG.03.04.01: medication labeling in the perioperative setting.
Jt Comm Perspect Patient Saf. December 2010;10:6-8.

Speaking up about safety concerns: multi-setting qualitative study of patients' views and experiences.
Entwistle VA, McCaughan D, Watt IS, et al; PIPS Group. Qual Saf Health Care. 2010;19:1-7.

Perceptions of hospital safety climate and incidence of readmission.
Hansen LO, Williams MV, Singer SJ. Health Serv Res. 2010 Nov 24; [Epub ahead of print].

Exploring relationships between hospital patient safety culture and adverse events.
Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. J Patient Saf. 2010;6:226-232.

Clinician mindfulness and patient safety.
Sibinga EMS, Wu AW. JAMA. 2010;304:2532-2533.

Medication reconciliation in the emergency department: opportunities for workflow redesign.
Hummel J, Evans PC, Lee H. Qual Saf Health Care. 2010;19:531-535.

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.
Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.
Dalal AK, Poon EG, Karson AS, Gandhi TK, Roy CL. J Hosp Med. 2010 Nov 15; [Epub ahead of print].

Effects of learning climate and registered nurse staffing on medication errors.

Chang Y, Mark B. Nurs Res. 2011;60:32-39.

The effect of medical emergency teams on patient outcome: a review of the literature.
Laurens NH, Dwyer TA. Int J Nurs Pract. 2010;16:533-544.

Organisational culture: variation across hospitals and connection to patient safety climate.
Speroff T, Nwosu S, Greevy R, et al. Qual Saf Health Care. 2010;19:592-596.

A human factors curriculum for surgical clerkship students.
Cahan MA, Larkin AC, Starr S, et al. Arch Surg. 2010;145:1151-1157.


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