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Quality Improvement & Patient Safety Section Newsletter - December 2009, Vol 11, #1

   Quality Improvement & Patient Safety Section

circle_arrow The Chair’s Letter
circle_arrow Editor’s Note
circle_arrow 2009 QIPS Annual Meeting Minutes
circle_arrow Mr. Potato Head Trauma Center
circle_arrow The AHRQ/ACEP Conference on Systems of Care: A Huge Success
circle_arrow The Power of 100
circle_arrow QIPS Tips 7, "Holding Your Own"
circle_arrow Quality and Safety Articles

Newsletter Index

Quality Improvement & Patient Safety Section



The Chair's Letter
Elaine Thallner, MD, MS, FACEP

Click here to e-mail Dr. Thallner

Elaine ThallnerI would like to thank Bob Broida for his leadership of the ACEP Quality Improvement and Patient Safety section during the past year.  Angela Franklin, JD serves as our section liaison, providing timely information, guidance, advice, and organizational skills, with a quite effective mix of professionalism and humor.  Thank you Angela!  

It is wonderful to have been a part of this successful section.  I have found the QIPS section to be highly functioning and filled with capable, interesting, talented, thoughtful, and fun individuals who enjoy accomplishing their goals. 

The mission of the QIPS Section is "to enable those physicians who have an interest or expertise in QI and PS to meet for the purpose of initiation, discussion, and development of ideas which will improve patient care."  I thank our section members for their support.  I think we meet the objectives of our mission and encourage you to join in as many activities as you are able, to make suggestions about how we can improve, share your thoughts and ideas, network, and learn with us in service of improving care. 

Briefly recapping our recent history, the QIPS section was awarded two awards during the October 2009 Scientific Assembly in Boston:  Section Newsletter Award of Distinction (2007-2008, Thallner) and the Service to Section Award (Chung).  This is the section’s fourth year in a row of receiving multiple awards! 

Last year we received a section grant to support a hand off study, led by Dickson Chung that resulted in an article published in Annals of Emergency Medicine. 

Over the past year, a group led by Jack Kelly, MD has been working to fine-tune and submit for publication a Quality Curriculum for Emergency Medicine.  This has also become an objective of Quality and Performance Committee. 

Led by our newsletter editor Drew Fuller, MD, we published 4 outstanding newsletters during the past year.  These are accessible on the ACEP website and showcase a richness and diversity of talent and thinking that does not happen in the absence of the editor’s leadership skills and a generous team of contributors. 

Under Dr Bob Broida’s leadership, our section increased in membership from 247 to 267. 

Strength is in numbers, so please encourage your colleagues to join this section.  In addition to the ‘strength argument’ for joining, there is a ‘value argument’:

Value = benefit/cost 

  • The cost of membership is $0 (if your group pays) or $35/year (if you pay)
  • The benefit of membership in QIPS is priceless, so this section is high benefit, low cost, and very high value. 

For this year, we will continue our tradition of high value newsletters, complete the quality curriculum, and apply for an ACEP Section Grant.  We welcome everyone who wishes to participate in whatever way you are able to do so. 

Introducing our section officers for 2009-2010:

Chair/alternate councilor Elaine Thallner, MD, MS, FACEP
Chair-Elect Drew Fuller, MD, MPH, FACEP
Secretary/Newsletter Editor Heather Farley, MD, FACEP
Councilor Bob Broida, MD, FACEP
ACEP Board Liaison Alexander M. Rosenau, DO, FACEP
Staff Liaison Angela Franklin, Esq.



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Editor's Note

Heather Farley, MD, FACEP


 Heather Farley Great news!  A new subject category has been added for the 2011 Research Forum: "Quality and Patient Safety".  This new category will not only be a better "fit" for the abstracts many of our section members author, but will also make it easier for those interested in quality and patient safety research to view the latest and greatest developments in the field.  Keep this in mind when submitting your abstracts next year!


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2009 QIPS Annual Meeting Minutes


Section officers participating: Robert I. Broida, MD, FACEP, Elaine A. Thallner, MD, FACEP, Drew C. Fuller, MD, FACEP, Dickson S. Cheung, MD, MBA, MPH, FACEP, and Heather L. Farley, MD, FACEP.  Others attending the meeting included: Andrew E. Sama, MD, FACEP, ACEP Board Liaison, staff liaison Angela Franklin, Esq., and Section members and guests totaling approximately 60 persons.


  • Chairs, Councillors report
  • Annual election
  • Educational offerings: Eric W. Dickson MD, MHCM, FAAEM, Dennis M. Beck, MD FACEP

Major Points Discussed

Dr. Broida reported on the Section activities over 2008-09, including the receipt of an ACEP Section Grant to pursue an ED Patient Hand-Off study, which resulted in a paper published in the Annals of Emergency Medicine September Supplement, entitled "Variation in the Practice of Emergency Department Handoffs".  

Dickson Cheung, MD, MBA, MPH, FACEP led the project; a Research Poster of the project was to be presented by Drew Fuller, MD, FACEP, entitled "Variation in the Practice of Emergency Department Handoffs," at Scientific Assembly.  Also, Jack Kelly, DO, FACEP, led a team of Section members to develop a comprehensive academic curriculum and reference list specifically focused on ED quality. This curriculum will be used by residency programs and others interested in ED quality resources. The project is complete and publication is being actively pursued.  

Finally, the Section was awarded both the ACEP Section Newsletter and ACEP Service to Section awards in October 2009. These awards were for the 2007-8 year, and reflect on the leadership of Dickson Cheung as Section Chair, and Elaine Thallner as Newsletter Editor.


Dr. Thallner reported that for 2009-10, the section plans to pursue various projects including pursuing, continuing the ED handoffs research, fleshing out the national ED Curriculum in conjunction with the Quality and Performance Committee,  improving the section Web site, increasing membership, and soliciting submissions for a new ACEP Section Grant.  

Dr. Eric Dickson, Professor of Emergency Medicine at the University of Massachusetts Medical School, was the featured speaker for the meeting, and led an exercise involving all participants that demonstrated the Lean (Toyota) model process improvement approach in the ED at the Mr. Potato Head Trauma Center. 

Dr. Dennis Beck, Chair of the Quality and Performance Committee, presented the Committee’s activities over 2008-09 and plans for 2009-10, as well as an effort by several ACEP members—the "Value Based Emergency Care" Task Force—to provide recommendations to the ACEP Board regarding positioning ACEP in light of emerging value-based purchasing initiatives at the national level. 

Dr. Andrew Sama also discussed the VBEC Task Force recommendations to the Board at length, which consisted of recommendations around Care Coordination, Episodes of Care, Possible Partnering with HRSA, and an ACEP Registry, and indicated that the Board would be deliberating possible next steps at its upcoming Strategic Planning Retreat. 



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Mr. Potato Head Trauma Center

Dickson Cheung, MD, MBA, MPH

Dr. Dickson CheungA terrible accident has occurred.  A bus full of Potato Heads has overturned outside the Boston Convention and Exhibition Center and the victims are horrifically dismembered.  Fortunately, the site of the mass casualty is near the annual QIPS meeting and there are plenty of "quality" emergency physicians on scene.  Photos of the survivors are found to help put them back together.  Four temporary operating tables are set up in short order and the QIPS members are off to save as many Potato Heads as possible.  Only correctly and completely assembled Potato Heads survive.  But only two team members have been credentialed to reimplant parts.  Every one else must help in setting up the pieces to be reimplanted. 

Dr. Eric Dickson, professor of emergency medicine, from the University of Massachusetts and a senior lecturer for the IHI led the QIPS section members through a fun and instructive exercise that demonstrated how Lean methodology and rapid cycle attempts (see below) can improve clinical processes.  Multiple 10 minute rounds were conducted as teams "learned" how to better reassemble the Potato Heads.  In his previous experiences, Dr. Dickson says that something magical happens usually on the third round where operational efficiency skyrockets.  Unfortunately, we only had enough time for two rounds but some teams already made considerable progress. 

Rapid Cycle Improvement Process

  • Define your improvement goal.
  • Define the current state using a process map and measures specific to your goal.
  • Redesign the process using ideas from the frontline staff (process redesign).
  • Measure again to determine the effect of your intervention.

Key points include involving frontline staff in the redesign process.  No one knows work processes better than the people who do it.  Not only do the best ideas frequently come from frontline staff but those ideas are usually more acceptable to the people who perform them.  Another key point is to make sure your most constrained capacity is constantly adding value.  In this case, the reimplantation specialists are best used by doing only what they can do, i.e. assemble the actual pieces back into Mr. Potato Head.  Similarly, physicians are best resourced by doing only what they can do.  Also, don’t waste time on intermediate processes that don’t meaningfully contribute to the end product, i.e. sorting out body parts.  Finally, don’t give up.  It usually takes 3-5 cycles of improvement before the major breakthrough occurs.  So, if you don’t first succeed, try again.  The "aha" moment may just be around the corner.


 Key Take Home Points

  • Identify bottlenecks
  • Front line staff suggestions are better and more acceptable than manager solutions
  • Quality of idea x Acceptability of idea = Likelihood of success
  • Make sure your most constrained capacity e.g. reimplantation specialist is constantly adding value
  • Orient new staff to an existing process

Mr. Potato Head Trauma Center 1 
 Mr. Potato Head Trauma Center 2


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The AHRQ/ACEP Conference on Systems of Care: A Huge Success

Jesse M. Pines, MD, MBA, MSCE

Jesse PinesOn October 4, 2009, more than 120 emergency physicians, hospital administrators, researchers, funders and other healthcare leaders gathered for an exciting one-day conference titled, "Improving the Quality and Efficiency of Emergency Care  Across the Continuum: A Systems Approach."  Conference co-chairs were Brent Asplin, MD, FACEP, Chair of Emergency Medicine at the Mayo Clinic and Jesse M. Pines, MD, MBA, MSCE, Assistant Professor of Emergency Medicine and Epidemiology at the Hospital of the University of Pennsylvania who is moving to George Washington University as of January 2010. 

The conference was the culmination of more than a year of work invested by ACEP staff, conference organizers, and participants. According to many of the attendees, the conference was a huge success. Many of the ideas discussed have the potential to change not only emergency care but also the wider healthcare delivery system across the United States. 

The morning keynote was eloquently delivered by Carolyn Clancy, MD, the Director of the Agency for Healthcare Research and Quality (AHRQ).  She talked about the role of federal funding in emergency care research and remarked on several granting mechanisms through AHRQ and other federal agencies are actively seeking projects studying care coordination and interventions to improve emergency care as part of the comparative effectiveness portfolio. 

There were two morning panels, one chaired by Dr. Asplin on ED Systems Workflow and Redesign and another on Improving Care Coordination for High-Cost Patients by Dr. Pines.  Highlights of the first session included Eugene Litvak, PhD, Professor of Health Care and Operations Management at the Boston University Health Policy Institute, who discussed the potential win-win of surgical schedule smoothing on ED flow.  Charlotte Yeh, MD, FACEP, an emergency physician and Chief Medical Officer at the American Association of Retired Persons (AARP) led the second panel by discussing a care coordination intervention that could potentially keep older adults out of the ED altogether by recognizing problems early and improving their functional status. 

The lunchtime keynote was given by Elliott Fisher, MD, MPH, Director of the Center for Health Policy Research at Dartmouth Medical School and a leader in the health services research.  Dr. Fisher gave a very entertaining talk on the healthcare variation by demonstrating how certain U.S. communities spend more on healthcare than others, and often don’t achieve the same outcomes. 

The afternoon sessions consisted of five groups who through a series of conference meetings and conference calls prior to the meeting developed a series of research aims for potential submission to either federal or foundation funders.  The groups discussed and sought participant input on their projects related to 1) Improving processes for the initial diagnosis and stabilization of acute, episodic care (chaired by Drs. Stephen Epstein and Jim Adams), 2) Designing systems to improve transitions after emergency care (chaired by Drs. Jeremiah Schuur and Brent Asplin), 3) Using information technology to improve the safety of acute care (chaired by Drs. Daniel Handel and Robert Wears), 4) Improving care and reducing costs for high-cost users (chaired by Drs. Jesse Pines and Don Yealy), and 5) Acute care at the end-of-life (chaired by Drs. Tammie Quest and Chuck Cairns). 

The conference organizers are currently working to develop a series of concepts papers for publication in the peer-reviewed literature while individual small group chairs have started to move forward with potential proposals for funding.  The conference was funded by an R13 grant from AHRQ and supported by the American College of Emergency Physicians, the Emergency Medicine Foundation, and the Society for Academic Emergency Medicine. 


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The Power of 100

Sections Task Force Board Liaison
Andrew Bern, MD, FACEP

Congratulations to all sections on their annual meetings during Scientific Assembly in Boston. This Scientific Assembly was a huge success having the most registrants of any Scientific Assembly to date.

BernAndyIn this past year, the Sections Task Force, chaired by Dr. Kelly Gray-Eurom and me, as the board liaison, oversaw the awarding of section grants and section awards in the categories of increased membership, newsletter excellence, service the college, and service to sections. In the next few weeks, we hope to receive the annual reports of each section on the activities for this past year. This report can be used in developing the self -nominating forms for service to college and service to section awards. It is also an historical record of the accomplishments of your section for the year that would be helpful for new section leaders and section members. This report is important to send out through the section e-list or to be printed in the first issue of your section’s newsletter.

At this year's Scientific Assembly a meet and greet was held for section leaders. Susan Morris, Bobby Heard, Kelly Gray-Eurom, and I met with section leaders between 8 am-9 am for coffee and doughnuts to share experiences and solutions as to problems facing section leaders.

Council Meeting

Some section councillors took advantage of the councillor training session and met with the small chapter and section caucus on Friday afternoon and Sunday morning. It is a tradition for section and small chapter councillors to assist each other with training and support during the Council meeting. Sections and small chapter councillors often have the role of councillor for only one year. Clearly, this is a disadvantage in experience when compared to larger chapters where councilors can serve many consecutive terms and truly get to know the system and the individuals. Section councillors and alternate councillors should plan on attending the councillor orientation and these important caucus meetings on Friday afternoon and Sunday morning next year. It is yet another opportunity for section leaders to get together and share common experiences.


Webinar, ACEP Sections: The Power of 100

This year, for the first time, a webinar was produced to help educate section leaders. The webinar can be accessed by clicking here. Although directed to the section leadership, any section member who in the future wants to become leader or just wants to know more about sections can go to the site.

I encourage each of you to listen to the webinar. Section members who have taken advantage of this resource tell me that it has been very helpful and is well worth the 40 or so minutes of their time to gain a really good understanding of what you can do with the section.

Growth in Section Membership

Your College, under the direction of the Membership Committee and Membership Division staff, has seen the successful growth of membership to more than 27,500 members. There has also been a growth in section membership. One of the reasons for this has been the block payment for residents by residency directors. Often, when this block payment occurs, complementary section selections for the resident are not made. This creates an opportunity for each section to be in contact with these new resident members and invite them to participate in your section. Sections offer many opportunities for residents in leadership development, professional development, and in publishing in the section newsletter.

Size matters- because sections can use 15% of the membership dues generated in the previous year to finance projects. Membership growth equates to more funds for projects. It is also important if you want to influence College direction.

Section Grant Program

About this time, many sections will begin to think about the section grant program. Documents outlining the grant program and how to apply for a grant are posted on the Section web site. Click here.

Communications and action plans

Now is the time to develop action plans for the section during this activity year. The communications plan details how the section will communicate with its membership through three different communication tools. These tools include the section newsletter, the section e-list, and the section website. Each of these tools should have an editor or project director. Ideas and survey results from the section e-list can be summarized in the section newsletter or website. Resources of a particular section might be carried in the section newsletter so it is always there for the members. Many sections use the annual meeting as an opportunity to define the topics that they will cover in the newsletter over the course of this year. With an average of 10 stories per newsletter, a section would be able to cover 40 different stories over the course of the year.


There are three types of partnerships that I would like to talk about. First, sections can partner with one another when applying for section grants. There have been many examples where two or more sections have worked with one another on grant projects. Second, sections have partnered with chapters in providing lectures as part of the chapter meeting and have become associated with specific meetings. Examples include the Disaster Medicine Section that has a meeting of the section at the Florida Chapter of Emergency Physicians’ disaster conference; the Emergency Medicine Informatics Section also has partnered with the Pennsylvania Chapter in their annual informatics meeting. These partnerships are a win-win for both the section and the chapter. The last partnership is the development of a course program that is so large that the partnership is between the section and college through the education committee that produces a dedicated program. The Pediatric Advanced Educational Program is an example of such a partnership.

The Team

We want your section to succeed. Happy and engaged members who find value in the community of others who share a similar interest within their practice of emergency medicine determine success. We look forward to each section reaching a goal of four newsletters, participating in the section grant program and in the ability to finance section projects through the 15% of dues allocation. We want to help each section member reach their full potential including professional development by using sections as an alternative path to leadership development. Finally, we would like to see each section member become politically engaged by attending the Leadership and Advocacy Conference in Washington DC this spring, the annual Council meeting next year in Las Vegas, and participating in NEMPAC and EMF. 


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QIPS Tips 7, "Holding Your Own"

Shari Welch, MD, FACEP

Shari WelchAs emergency departments are being forced increasingly to operate in overcapacity situations, patients who may not need admission, but who require 4 to 8 hours of ED services, pose a liability when trying to maximize operational efficiency.  Over ten years ago Dr. Louis Graff first proposed the idea of observation units.  He had in mind patients who needed 24 hours of care to improve (asthmatics, overdoses, diabetics) or prolonged diagnostic work-ups (patients needing observation for possible abdominal pain or chest pain).  With advances, the diagnostic uncertainty of the latter group can be alleviated with CT scans and stress tests in under 24 hours, thus avoiding even the observation stay.  On the other hand they frequently need more than four hours of ED care.  Thence the concept of the Clinical Decision Unit or CDU. 

Such an area would ideally be a large multifunctional space much like the "wards" of older hospitals.  They would be designed for less therapeutic intensity than the main ED and would likely be staffed by less skilled workers such as ED Techs.  Attention would be paid to comfort and diversion (through movies, magazines, radio, family members) in this area.  ED Techs would maximize their skills at keeping patients comfortable (ice packs, blankets) while communicating with their nursing team members if patients have any medical problems ( example: requests more pain medicine).  Bear in mind that the gap between RN full-time equivalents versus requirements will continue to widen to a shortage of 800,000 by 2020. 


 Characteristics of The Clinical Decision Unit

  •     Multifunctional Open Space
  •     Designed for Less Therapeutic Intensity
  •     Designed for Patient Comfort (blanket warmer, ice packs)
  •     Built In Diversions (Television, Radio, Reading Material)
  •     Staffed by ED Technicians

Such Clinical Decision Units would keep the main ED beds open for patients requiring a higher level of therapeutic intensity or diagnostic procedures and would keep nurses dedicated to doing nursing care.  In this model, patients waiting for CT, MRI, stress testing, would be shuttled to the "holding area".  Likewise, patients waiting for subspecialty consultations who are stable (ie: waiting for the plastic surgeon or orthopedist) could be placed in this holding area or CDU.   In addition, patients requiring such prolonged work-ups would have the sense of moving through the system by physically advancing to the CDU. 


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Quality and Safety Articles

Helmut Meisl, MD, FACEP

Here again is a list of recent articles for your interest. These are compiled
by AHRQ PSNet at (
meislDiagnostic error in medicine: analysis of 583 physician-reported errors.
Schiff GD, Hasan O, Kim S, et al. Arch Intern Med. 2009;169:1881-1887.

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.
López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894.

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?
Pingleton SK, Horak BJ, Davis DA, Goldmann DA, Keroack MA, Dickler RM. Acad Med. 2009;84:1510-1515.

Testing the association between Patient Safety Indicators and hospital structural characteristics in VA and nonfederal hospitals.
Rivard PE, Elixhauser A, Christiansen CL, Zhao S, Rosen AK. Med Care Res Rev. 2009 Oct 30.

Emergency physician perceptions of patient safety risks.
Sklar DP, Crandall CS, Zola T, Cunningham R. Ann Emerg Med. 2009 Oct 23.

The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study.
Calzavacca P, Licari E, Tee A, et al. Resuscitation. 2009 Oct 23.

Ensuring patient safety through effective leadership behaviour: a literature review.
Künzle B, Kolbe M, Grote G. Safety Sci. 2010;48:1-17.

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.
Millard WB. Ann Emerg Med. 2009;54:A25-A29.

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

Lightdale JR, Mahoney LB, Fredette ME, Valim C, Wong S, DiNardo JA. J Perianesth Nurs. 2009;24:300-306.

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.
ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.
Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-2912.

Did duty hour reform lead to better outcomes among the highest risk patients?
Volpp KG, Rosen AK, Rosenbaum PR, et al. J Gen Intern Med. 2009;10:1149-1155.

On the prospects for a blame-free medical culture.
Collins ME, Block SD, Arnold RM, Christakis NA. Soc Sci Med. 2009;69:1287-1290.

Variations in nursing care quality across hospitals.
Lucero RJ, Lake ET, Aiken LH. J Adv Nurs. 2009;65:2299-2310.

Rate of undesirable events at beginning of academic year: retrospective cohort study.

Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. BMJ. 2009;339:b3974.

Medication reconciliation in ambulatory care: attempts at improvement.
Nassaralla CL, Naessens JM, Hunt VL, et al. Qual Saf Health Care. 2009;18:402-407.

Safety and risk management interventions in hospitals: a systematic review of the literature.
Dückers M, Faber M, Cruijsberg J, Grol R, Schoonhoven L, Wensing M. Med Care Res Rev. 2009 Sep 16.

Improving handoffs in the emergency department.
Cheung DS, Kelly JJ, Beach C, et al; for the American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Ann Emerg Med. 2009 Oct 1; [Epub ahead of print].

Impact of duty-hour restriction on resident inpatient teaching.
Mazotti LA, Vidyarthi AR, Wachter RM, Auerbach AD, Katz PP. J Hosp Med. 2009;4:476-480.

Risks of complications by attending physicians after performing nighttime procedures.

Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

The natural history of recovery for the healthcare provider "second victim" after adverse patient events.
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. Qual Saf Health Care. 2009;18:325-330.

Quality of medication use in primary care—mapping the problem, working to a solution: a systematic review of the literature.
Garfield S, Barber N, Walley P, Willson A, Eliasson L. BMC Med. 2009;7:50.

Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital.
Chan EW, Taylor SE, Marriott JL, Barger B. Med J Aust. 2009;191:374-377.

Delays and errors in cardiopulmonary resuscitation and defibrillation by pediatric residents during simulated cardiopulmonary arrests.
Hunt EA, Vera K, Diener-West M, et al. Resuscitation. 2009;80:819-825.

Variation in hospital mortality associated with inpatient surgery.
Ghaferi AA, Birkmeyer JD, Dimick JB. N Engl J Med. 2009;361:1368-1375.

Pediatric adverse drug events in the outpatient setting: an 11-year national analysis.
Bourgeois FT, Mandl KD, Valim C, Shannon MW. Pediatrics. 2009;124:e744-e750.

The nature and causes of unintended events reported at ten emergency departments.
Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. BMC Emerg Med. 2009;9:16.

Comparing safety climate between two populations of hospitals in the United States.
Singer SJ, Hartmann CW, Hanchate A, et al. Health Serv Res. 2009;44:1563-1583.

The "July phenomenon": is trauma the exception?
Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC. J Am Coll Surg. 2009;209:378-384.

Implementing patient safety initiatives in rural hospitals.
Klingner J, Moscovice I, Tupper J, Coburn A, Wakefield M. J Rural Health. 2009;25:352-357.

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.

Clinicians' assessments of electronic medication safety alerts in ambulatory care.
Weingart SN, Simchowitz B, Shiman L, et al. Arch Intern Med. 2009;169:1627-1632.

Putting safety on the curriculum.
Ellis O. BMJ. 2009;339:b3725.

Association of resident fatigue and distress with perceived medical errors.

West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. JAMA. 2009;302:1294-1300.

Disclosing harmful medical errors to patients: tackling three tough cases.
Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Chest. 2009;136:897-903.

Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals.

Jha AK, Chan DC, Ridgway AB, Franz C, Bates DW. Health Aff (Millwood). 2009;28:1475-1484.

Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patients: a randomized, controlled trial.
Terrell KM, Perkins AJ, Dexter PR, Hui SL, Callahan CM, Miller DK. J Am Geriatr Soc. 2009;57:1388-1394.

Association of resident fatigue and distress with perceived medical errors.
West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. JAMA. 2009;302:1294-1300.

Hospitalist handoffs: a systematic review and task force recommendations.
Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.
Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

Medical error reporting, patient safety, and the physician.

Anderson B, Stumpf PG, Schulkin J. J Patient Saf. 2009;5:176-179.

Patient safety in intensive care medicine: the Declaration of Vienna.
Moreno RP, Rhodes A, Donchin Y. Intensive Care Med. 2009 Aug 21; [Epub ahead of print].

Strategies for safe medication use in ambulatory care settings in the United States.
Sorensen AV, Bernard SL. J Patient Saf. 2009;5:160-167.

The negative impact of nurse-physician disruptive behavior on patient safety: a review of the literature.
Saxton R, Hines T, Enriquez M. J Patient Saf. 2009;5:180-183.

Improving communication in the emergency department.

Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-661.

Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.
Hsiao AL, Shiffman RN. Jt Comm J Qual Patient Saf. 2009;35:467-474.

How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
Lanham HJ, McDaniel RR, Crabtree BF, et al. Jt Comm J Qual Patient Saf. 2009;35:457-466.

Identifying vulnerabilities in communication in the emergency department.
Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:653-657.

Improving communication in the emergency department.
Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-661.

The effects of on-screen, point of care computer reminders on processes and outcomes of care.

Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. Cochrane Database Syst Rev. 2009;(3):CD001096.

Setting priorities for patient safety: ethics, accountability, and public engagement.
Pronovost PJ, Faden RR. JAMA. 2009;302:890-891.

Out-of-hospital medication errors: a 6-year analysis of the national poison data system.
Shah K, Barker KA. Pharmacoepidemiol Drug Saf. 2009 Aug 14; [Epub ahead of print].

Effect of work-hours regulations on intensive care unit mortality in United States teaching hospitals.
Prasad M, Iwashyna TJ, Christie JD, et al. Crit Care Med. 2009;37:2564-2569.

Rapid response systems in adult academic medical centers.
Wood KA, Ranji SR, Ide B, Dracup K. Jt Comm J Qual Patient Saf. 2009;35:475-482.

How does the law recognize and deal with medical errors?
Merry AF. J R Soc Med. 2009;102:265-271. 


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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