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Journals and Conferences
The authors describe HFMEA, a five-step process used to proactively evaluate a health care process, and provide examples of a team's forms and actions regarding prostate-specific antigen testing.
BACKGROUND The Veterans Administration (VA) identified patient safety as a high-priority issue in 1997 and implemented the Patient Safety Improvement (PSI) initiative throughout its entire health… (More)
BACKGROUND Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans… (More)
CONTEXT There is insufficient information about the effectiveness of medical team training on surgical outcomes. The Veterans Health Administration (VHA) implemented a formalized medical team… (More)
MORE THAN A DECADE AFTER THE INSTITUTE OF Medicine reported problems with the quality and safety of US health care, formal training of the health care workforce in quality and patient safety is still… (More)
The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork… (More)
CONTEXT Unplanned readmission within 30 days of discharge is an indicator of hospital quality. PURPOSE We wanted to determine whether older rural veterans who were enrolled in the VA had different… (More)
CONTEXT Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health… (More)
The authors describe use of aggregate root cause analysis, which provides a systematic process for analyzing high-priority, frequent events.
The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and its member boards introduced the six domains of physician competency in 1999. This… (More)