• Publications
  • Influence
'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, andExpand
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Adverse drug event trigger tool: a practical methodology for measuring medication related harm
Adverse drug events continue to be the single most frequent source of healthcare mishaps, continually placing patients at risk of injury. This is not unexpected, given that drug treatment is the mostExpand
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Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.
BACKGROUND A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may alsoExpand
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Methodology and rationale for the measurement of harm with trigger tools
The growing recognition of harm as an unwelcome and frequently unrecognized byproduct of health care has initiated focused efforts to create highly reliable organizations for safe healthcareExpand
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Medication Safety: One Organization's Approach to the Challenge
The Institute of Medicine report To Err Is Human has led to increased recognition of the problem of safety in the U.S. health system [1]. Subsequent studies have continued to document the need forExpand
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Patient Flow in Hospitals: Understanding and Controlling It Better
Summary • Because waits, delays, and cancellations are so common in healthcare, patients and providers assume that waiting is an inevitable, but regrettable, part of the care process. For years,Expand
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Basics of quality improvement in health care.
With the rapid expansion of knowledge and technology and a health care system that performs far below acceptable levels for ensuring patient safety and needs, front-line health care professionalsExpand
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Sepsis change bundles: converting guidelines into meaningful change in behavior and clinical outcome.
The incidence of severe sepsis (sepsis with organ dysfunction) is increasing (1). Several recently published studies have demonstrated decreased mortality and morbidity as a result of interventionsExpand
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Standardization as a mechanism to improve safety in health care.
BACKGROUND A growing body of literature shows that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety may be compromised. A multispecialty group at LutherExpand
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Making noncatastrophic health care processes reliable: Learning to walk before running in creating high-reliability organizations.
  • R. Resar
  • Medicine
  • Health services research
  • 1 August 2006
Health care clinicians successfully apply proven medical evidence in common acute, chronic, or preventive care processes less than 80 percent of the time. This low level of reliability at the basicExpand
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