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Risk Management Pearls – Medication Safety Part I. American Society for Healthcare Risk Management; 2013.
(Call No. R M 151-130 2014 Part I)
Risk Management Pearls – Medication Safety Part II. American Society for Healthcare Risk Management; 2013.
(Call No. R M 151-130 2014 Part II)
Safe patient handling training for schools of nursing.: NIOSH. National Institute for Occupational Safety & Health; 2009. Describes safe patient handling (SPH) techniques, using assistive device or more than one caregiver for transfer.
(Call No. DVD 002-610)
Patient safety improvement guidebook. Patrice L. Spath. Brown-Spath & Associates; 2000. This book offers step-by-step instructions for designing and implementing an effective proactive patient safety management initiative. Topics include: measuring important elements of patient safety; how to identify the error-producing factors in high risk patient care processes; using comparative data to establish improvement opportunities; techniques for error-proofing health care services to prevent future patients from being harmed by mistakes; and how to create a patient-safe work culture.
(Call No. QA CQI 148-098)
Hazard vulnerability analysis toolkit: Assessing risk to patients and preparing for all disasters. Opus Communications & The Greeley Company; 2002. The workbook includes the following topics: How to use the HVA-Patient Safety Toolkit, HVA can help you select FMEA topic, what is an FMEA?, environment of care topics. Develop a plan, implement the plan, evaluate and modify plan, examples of training drills. The Toolkit will assist hospitals in the following ways: Assessing the risks they face from every possible kind of disaster or emergency, assessing risks from sentinel events, meeting JCAHO's emergency planning and patient safety standards, training staff and performing preparedness drills.
(Call No. Safety 152-100)
Essentials of aggression management in healthcare. Steven S. Wilder and Chris Sorensen. Princeton Hall; 2002. The authors have trained thousands of healthcare professionals in dealing with aggressive behavior and how to recognize the six behavior changes a person goes through between "calm and physically violent."
(Call No. R M 151-119)
Bathing without a battle. University of North Carolina at Chapel Hill, 2003. The DVD is a valuable learning tool for families who have been affected by Alzheimer's disease and related disorders, as well nursing home personnel. The CD-ROM offers instruction and advice on personalized bathing and is useful for all nursing home personnel.
(Call No. DVD 002-601)
Surgical patient safety – essential information for surgeons in today’s environment. Barry M. Manuel. American College of Surgeons; 2004. The authorization of this book by ACS is another of its many initiatives to improve the safety of the U. S. health care systems. The purpose of the book is to provide guidance and leadership in evolving areas of patient safety to the broadest possible number of ACS Fellows and to other interested parties.
(Call No. Surgery 167-033)
Keeping patients safe: Transforming the work environment of nurses. Ann Page, Editor. National Academy of Sciences; 2004. Building on the revolutionary IOM reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform – monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis – provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care – and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking IOM Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
(Call No. Nursing 556-116)
Strengthening nurse-physician relationships: A guide to effective communications. HCPro; 2005. Honest and direct, this video reveals communication problems that exist in many healthcare organizations and offers strategies to avoid disconnects and animosity. Filled with field-tested, how to strategies, tips, and advice, nurses will learn how to take control of negative situations and be a true advocate for their patient.
(Call No. DVD 002-551)
TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. Agency for Healthcare Research and Quality; 2006. Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. This program has been widely implemented across several health care settings; it has even been successfully applied in medical student curricula. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors.
(Call No. DVD 002-605)
Strategies for building a hospitalwide culture of safety. Joint Commission Resources; 2006. The ideas and lessons represented in this new book - a collection of articles from the Joint Commission Journal on Quality and Patient Safety - can help health care organizations develop and refine their culture of safety and achieve better patient outcomes and overall better performance. Allan Frankel, M.D., Director of Patient Safety, Partners Healthcare, Boston, provides commentary on the articles.
(Call No. R M 151-121)
Meeting the Joint Commission’s 2007 national patient safety goals. Joint Commission Resources; 2006. This book includes previously published articles from various JCR publications and provides detailed information on topics such as: improving the accuracy of patient identification; improving the safety of using high-alert medications; accurately reconciling medications across the continuum of care; reducing the risk of patient harm resulting from falls; preventing health care-associated pressure ulcers; encouraging patients' active involvement in their own care; improving hand-off communication; and using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
(Call No. Hlth Care Adm 310-101 2007)
Medical emergency teams: Implementation and outcome measurement. Michael A. DeVita. Springer Publishing Company; 2006. The book addresses the problem of patient safety and quality of care; the logistics of creating a MET (resource allocation, process design, workflow, and training); the implementation of a MET (organizational issues, challenges); and the evaluation of program results. Based on successful MET models that have resulted in reduced in-hospital cardiac arrest and overall hospital death rates, this book is the first practical guide for physicians, hospital administrators, and other healthcare professionals who wish to initiate a MET program within their own institutions.
(Call No. E R Svcs 079-038)
Medication reconciliation handbook. Darryl S. Rich. Joint Commission Resources; 2006. The handbook is an invaluable tool for health care organizations seeking to implement an effective medication reconciliation process. Medication errors commonly occur at points of transition in care, such as at admission, during transfer from one department to another, or at discharge. A medication reconciliation process can help your organization decrease the incidents of medication errors at these points. Numerous case studies describe successes in forming a team to incorporate medication reconciliation in their processes. The Joint Commission's National Patient Safety Goal on medication reconciliation is also discussed.
(Call No. Nursing 556-133)
Hand-off communication: Practical strategies and tools for JCAHO compliance. Kurt A. Patton. HCPro, Inc.; 2006. The book explains the JCAHO's requirements and offers clear advice for compliance. The book explores many of the problems and challenges you face during the hand-off process, developing a policy and implementing it, and identifies the resources you'll need to meet the surveyor scrutiny.
(Call No. QA CQI 148-106)
Guide to patient safety in the medical practice. American Medical Association; 2006. An in-depth review into the risks and consequences of errors and adverse events in ambulatory care. This book begins with an historical perspective of patient safety and the important role it plays today with regards to: medical liability, medication dosages, EHRs, potentially problematic drugs lists, and rules for satisfying patient needs. Included case-studies provide additional in-sight for patient safety in the medical practice. Emphasis is also given to creating a business model and system support to accomplish your patient safety initiative.
(Call No. Amb Care 068-061)
Getting results – reliably communicating and acting on critical test results. Gordon D. Schiff. Joint Commission Resources; 2006. Improving the communication of critical test results in a reliable and timely manner is recognized as a major imperative in patient safety. The book reviews case studies on medical testing process errors.
(Call No. Phys 539-048)
Falls prevention strategies in healthcare settings: Patient, resident, worker, and visitor. ECRI; 2006. The guide is designed to help acute care and long-term care facilities develop or assess and improve their current falls reduction programs. It includes tools to assist readers in developing their own falls prevention programs.
(Call No. Safety 152-110)
Engaging physicians in patient safety: A handbook for leaders. Joint Commission Resources; 2006. This book is an invaluable tool for health care organizations seeking better physician involvement. This book will provide health care leaders with the information they need to understand how to make physicians want to be involved and the tools they need to effectively engage physicians in the organization's patient safety initiatives.
(Call No. Phys 539-043)
Critical test results troubleshooter. Gayla Jackson. HCPro; 2006. Poor communication of critical test results is a leading cause of sentinel events. The Joint Commission's National Patient Safety Goal #2 aims to improve reporting of critical test results. Many hospitals have implemented CTR systems, but continue to struggle with issues including the definitions of critical test values, timely reporting of results, and handoffs.
(Call No. Phys 539-059)
Understanding and implementing the 2008 patient safety goals. KRM Information Services, Inc.; 2007. In this audioconference, the first part will present key changes and additions to the goals for 2008. The second part will provide a model process for implementing the new goals.
(Call No. Audio CD 561-170)
Suicide risk assessment: Practical strategies and tools for Joint Commission compliance. HCPro; 2007. Year in and year out, patient suicide tops The Joint Commission's list of sentinel events. If your healthcare organization admits and treats patients with primary psychiatric symptoms, The Joint Commission's National Patient Safety Goal (NPSG) requires you to screen patients for suicide risk. This book and CD-ROM set help you determine when, and how, to identify and screen patients for suicide risk, as well as educate staff and provide a safe care environment. Suicide Risk Assessment: Practical Strategies and Tools for Joint Commission Compliance will help you develop or fine-tune your facility's assessment and prevention policies with an eye toward effective patient care, and greater staff awareness.
(Call No. R M 151-137)
Strategies for a successful physician handoff. HCPro, Inc.; 2007. Listen to two residency experts for this 90-minute audioconference. Hear strategies and how-to advice for developing consistent handoff processes that both meet Joint Commission requirements and ensure quality and safety through continuity of care.
(Call No. Audio CD 561-163)
Staffing effectiveness in hospitals, 2nd edition. Joint Commission Resources; 2007. Staffing Effectiveness in Hospitals, Second Edition is a guide to complying with The Joint Commission's revised staffing-related standards. The book focuses specifically on the staffing effectiveness requirement (HR.1.30), as well as on other related standards under the Leadership (LD) and Performance Improvement (PI) functions. Case studies and examples from accredited hospitals that exemplify successful implementation of staffing effectiveness requirements are included. You'll learn how to select and define indicators, collect and analyze data, and present and implement the analyzed results; specific strategies for staff recruitment and retention; tips for ensuring quality and safety using the staffing standards; and sample tools, charts, and graphs appear throughout the publication to guide you through the assessment process.
(Call No. Hosp Adm 312-050)
Patient safety on the line: Using technology to aid effective communication among caregivers. Joint Commission Resources; 2007. Patient safety literally is "on the line" every time a clinician communicates about a patient, especially when it involves critical or urgent test results or critical values. Multiple handoffs between care providers, distractions, demands on staff and physician time, and the speed with which orders and test results must frequently be accomplished can all contribute to delays and miscommunication. Fortunately, many health care organizations are starting to embrace new technology-based solutions that are enabling more effective and efficient communications and improving patient safety. This new strategy shows how patient safety and efficient systems are two sides of the same coin. Like all innovations, however, this technology-based solution must be understood and used appropriately to be effective. The purpose of this program is to provide health care organizations, through expert interviews and case study presentations, with information about an important new technology-based strategy for improving efficiency and aiding communication among caregivers: critical test result management (CTRM).
(Call No. DVD 002-534)
Meeting the Joint Commission’s 2008 national patient safety goals. Joint Commission Resources; 2007. The book features articles, book excerpts, tips and suggestions for complying with the goals and their requirements. Topics addressed include improving the accuracy of patient identification; improving the safety of using high-alert medications, including anticoagulation therapy; accurately reconciling medications across the continuum of care; reducing the risk of patient harm resulting from falls; improving recognition and response to changes in a patient's condition; encouraging patients' active involvement in their own care; improving hand-off communication; and using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
(Call No. Hlth Care Adm 310-101 2008)
Medication errors. Michael Cohen. American Pharmacists Association; 2007. Dr. Cohen brings together some 30 experts from pharmacy, medicine, nursing, and risk management to provide the most current thinking about the causes of medication errors and strategies to prevent them.
(Call No. R M 151-076 2007)
Aortic dissection at any age: The Tyler Kahle story. Methodist Health System Services; 2007. Since the “Aortic Dissection at Any Age: Tyler Kahle Story” debuted in August 2007 by the Methodist Health System , it has been viewed online more than 12,800 times by people in 53 countries and all 50 U.S. states – and average of 14 viewings each day. The organization is They are involved in writing the new guidelines for proper management of thoracic aortic dissection that will be published by the American College of Cardiology and American Heart Association, perhaps as early as March 2010.
(Call No. DVD 002-600)
Reducing the risk of patient harm resulting in falls: Toolkit for implementing NPSG 9. Joint Commission Resources; 2008. The toolkit includes an implementation guide that offers strategies and other how-to information to help organizations do the following: Improve assessment and reassessment techniques to identify at-risk individuals, choose more effective interventions to reduce fall risk factors, educate patients and gain their cooperation to reduce falls, train new staff members or provide additional training for veteran staff, consistently evaluate and use organizationwide falls data to make changes, learn how five healthcare organizations created multifaceted programs to reduce falls and how they made improvements when needed. The implementation guide also has a companion CD-ROM filled with forms, worksheets, quizzes, and other tools from the book that an organization can customize and use for its own falls reduction initiative.
(Call No. QA CQI 148-111)
New CMS policy on preventable injuries. Strafford Publications, Inc.; 2008. The panel reviewed these and other key questions: What types of medical errors are covered under the new CMS policy? Is a preventable error considered negligence per se under the new policy? How can health care providers limit their liability exposure for patient mistakes? What are the best practices for providers to follow to protect their Medicare provider status?
(Call No. Audio CD 561-165)
Medication use: A systems approach to reducing errors, second edition. Joint Commission Resources; 2008. Completely updated material reflecting advancements and research in the area of preventing medication errors. Learn how to involve physicians, nurses, pharmacists, caregivers, and patients in a safe medication use system.
(Call No. QA CQI 148-110)
Medication management – you can prevent errors!. Coastal Health Train; 2008. This updated DVD will teach your staff about medication errors, how big the problem is, and how errors can be prevented by using standards for medication safety. The program includes how to avoid risky behavior when handling high risk medications. English and Spanish versions are included, along with a customizable PowerPoint® presentation.
(Call No. DVD 002-537)
Handoff communications: Toolkit for implementing the NPSG. Joint Commission Resources; 2008. The Joint Commission's NPSG 2E (Implement a standardized approach to handoff communications.) is designed to help health care organizations prevent communication breakdowns that result in patient harm. Created to help organizations understand an implement NPSG 2E, this ready-to-use toolkit includes a spiral-bound Implementation Guide that explains how to implement proper handoff communication processes and techniques, with case studies on effective handoff programs. The accompanying CD-ROM contains more than 40 additional tools and resources to help organizations create or improve their patient handoff process, including practical forms, slide presentations, handouts, and video clips.
(Call No. QA CQI 148-109)
Engaging patients as safety partners: A guide for reducing errors and improving satisfaction. American Hospital Association; 2008. A how-to book for creating patient-caregiver relationships that improve patient safety. The book aids health care professionals in understanding how patients and families can partner with practitioners to reduce medical errors and how practitioners can mitigate the effects of mistakes when they do occur. It helps health care professionals recognize and overcome barriers that inhibit consumer involvement in patient safety improvement. It also provides valuable advice on how to surmount legal concerns associated with patient/practitioner collaboration.
(Call No. R M 151-125)
Dialysis safety – critical measures for success. ECRI; 2008. Twenty-seven percent of dialysis patients witnessed at least one medical error in the three months prior to a survey, according to a presentation by Alan S. Kliger, M.D. Kliger's presentation was part of an August 13, 2008, ECRI Institute Webinar, "Dialysis Safety: Critical Measures for Success." The survey respondents, 1,762 in-center hemodialysis patients and 649 dialysis care providers, identified several safety issues present in dialysis units, including inadequate hand hygiene, medication errors, patient falls, and incorrect dialysis setup or procedures. Thirty percent of the providers surveyed indicated that medical mistakes occurred more than rarely at the dialysis unit, and 59% reported believing that most medical mistakes related to the failure of staff to follow procedures. The survey also found that 5% of the patients experienced at least one fall at the dialysis unit during the three months prior to the survey, suggesting that patient falls are a frequent source of adverse events. Strategies suggested by Kliger to improve safety at dialysis centers included ensuring that hand hygiene protocols are followed, reviewing medications with patients more frequently, improving assessment of patients for risk factors for falls, and participating in the Centers for Medicare & Medicaid Services' Quality Assessment Performance Improvement Program.
(Call No. Audio CD 561-174)
Understand The Joint Commission’s Universal Protocol: Keeping patients safe from wrong-site surgery. HCPro; 2009. Data from the field shows that wrong-patient, wrong-site, and wrong-procedure surgeries are on the rise. In just 20 minutes, you and your staff can learn how to properly and effectively perform the three requirements of The Joint Commission's Universal Protocol. By watching these realistic clinical scenarios, you can ensure staff follow the correct steps to keep patients safe and in compliance.
(Call No. DVD 002-549)
Sharing practices that prevent falls, pressure ulcers, and infections. KRM Information Services, Inc.; 2009. To minimize falls, pressure ulcers and catheter-related infections in acute care facilities, leaders there must adopt successful strategies from LTC colleagues. This audio conference will cover key components that have been successfully implemented in both LTC and acute care environments. Discussion will cover lessons learned and risk mitigation for falls, pressure ulcers and UTIs. Faculty will share recommendations to reduce risk and enhance patient safety.
(Call No. Audio CD 561-177)
Role of hospitalists in patient safety. 2009. The book addresses the urgency of patient-centric care for the nearly 30,000 hospitalists expecting to be practicing in North America and abroad by the year 2010, including a focus on areas crucial to hospitalists' practices. It includes a foreword from Robert M. Wachter, M.D., a leader in the hospitalist movement, and is co-published with the Society of Hospital Medicine. The book also discusses ways hospitalists can improve patient safety, explains how TJC standards and the NPSGs can direct hospitalists toward patient-centric care and offers real-world examples of how hospitalists are making patients safer within their organizations.
(Call No. Med Staff 113-092)
Meeting the Joint Commission’s 2009 national patient safety goals. Joint Commission Resources; 2009. Meeting the Joint Commission's 2009 National Patient Safety Goals provides detailed information on topics such as improving the accuracy of patient identification, improving the safety of using high-alert medications, accurately reconciling medications across the continuum of care, reducing the risk of patient harm resulting from falls, preventing health care-associated pressure ulcers, encouraging patients' active involvement in their own care, improving handoff communication, using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
(Call No. Hlth Care Adm 310-101 2009)
Unmet needs: Teaching physicians to provide safe patient care. Lucian Leape Institute Roundtable. National Patient Safety Foundation; 2010. Medical schools face an urgent need to transform their curricula to emphasize patient safety, according to this report from the Lucian Leape Institute at the National Patient Safety Foundation. Based on a roundtable discussion among leading medical education and patient safety experts, this report concludes that the traditional curricular focus on medical knowledge and technical expertise must shift to incorporate key concepts in systems analysis and patient-centered care. The piece includes specific recommendations for medical school and academic medical center leadership to develop rigorous safety curricula and evaluation methods. The report also emphasizes the importance of a culture of safety in teaching hospitals, stressing that unprofessional behavior and authority gradients prevent students from reporting and learning from errors.
(Call No. QA CQI 148-114)
Safe injection practices – a video for healthcare providers: One and only one campaign. Safe Injection Practices Coalition; 2010. The Safe Injection Practices video for healthcare providers is designed to remind healthcare providers to consistently utilize basic, evidence-based, common sense precautions to protect patients and themselves. The video opens with a personal story from Evelyn McKnight who contracted Hepatitis C virus when her healthcare providers did not adhere to safe injection practices. The viewer is then presented with three scenarios in three settings where medications are prepared and administered: an operating room, an oncology clinic, and a pain management clinic. The viewer is taken through potential errors that could occur in medication handling or injection preparation or administration. Each scenario ends with a summary of steps that can and should be taken to assure safe care. A fourth segment concludes the video by outlining and correcting myths and misperceptions that healthcare providers may have about safe injection practices.
(Call No. DVD 002-547)
Radiation therapy errors: Protecting patients from harm. ECRI; 2010. The web conference speakers discuss risks, impact and potential solutions for patient safety in radiation therapy.
(Call No. DVD 002-540)
Meeting the Joint Commission’s 2010 national patient safety goals. Joint Commission Resources; 2010. Understand how to meet the Joint Commission's 2010 NPSGs with these valuable articles, book excerpts, useful tips, and suggestions. This book includes previously published articles from various JCR publications and provides detailed information on topics such as improving the accuracy of patient identification, timely reporting of critical test results and values, safety of using high-alert medications and reducing the risk of patient harm resulting from falls, preventing health care-associated pressure ulcers, and using the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.
(Call No. Hlth Care Adm 310-101 2010)
Medication error prevention – six steps to improving patient safety. HCPro; 2010. Medication management has always been challenging for hospitals, but with recent media coverage of preventable, life-threatening medication errors, the subject issue has become even more critical. In addition, The Joint Commission's National Patient Safety Goals make medication management a point of focus each year. The program provides visual keys to help staff retain the lessons learned and identify their own behaviors regarding medication management.
(Call No. DVD 002-553)
Managing aggressive behaviour in care settings: Understanding and applying low arousal approaches. Andrew A. McDonnell. Wiley-Blackwell; 2010. This is a practical guide for health professionals and trainers, offering evidence-based low arousal approaches to defusing and managing aggressive behaviors in a variety of health care settings. It provides both an academic background and practical advice on how to manage and minimize confrontation. It illustrates low arousal approaches and offers clear advice on physical restraint. It describes the evidence base for recommended approaches. It includes wide range of valuable case examples.
(Call No. R M 151-133)
Workplace bloodborne pathogens for healthcare training. National Safety Compliance, Inc.; 2011. The video is 16 minutes and addresses the major areas needed to comply with the standard, including the contents of the OSHA standard, epidemiology & symptoms of bloodborne diseases, the modes by which bloodborne diseases are transmitted, an Exposure Control Plan, PPE - personal protective equipment, practices to prevent exposure, BBP signs, labels & containers, emergency procedures, follow-up procedures.
(Call No. DVD 002-602)
Occurrence reporting – building a robust problem identification and resolution process. Kenneth R. Rohde. HCPro; 2011. This new resource provides practical techniques to help you better analyze your occurrence reporting process, use your data to gain superior insight into why errors occur at your organization, and make improvements that decrease adverse events and enhance patient care.
(Call No. QA/CQI 148-116)
Error reduction in health care: A systems approach to improving patient safety. Patrice L. Spath. Jossey Bass Publishers; 2011. Completely revised and updated. The book includes a step-by-step guide for implementing the recommendations of the IOM to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur, including, analyzing accidents and using systematic methods to understand hazards before an accident occurs.
(Call No. R M 151-084 2011)
Advancing effective communication, cultural competence, and patient- and family-centered care: A road map for hospitals. The Joint Commission; 2010. The chapters within the Roadmap for Hospitals address the following components of the care continuum: Admission, Assessment, Treatment, End-of-Life Care, Discharge and Transfer and Organization Readiness.
(Call No. Hosp Adm 312-053)