The Official Journal of the
National Association for Healthcare Quality

Guest Editorial: It’s Time for a Comprehensive Interdisciplinary Patient Safety Taxonomy
Jacqueline Fowler Byers, Joann Genovich-Richards, Lynn Unruh 

Making the Patient Safety and Quality Improvement Act of 2005 Work Radhika Vemula, R. Robyn Assaf, A. F. Al-Assaf

Abstract: Successful implementation of the Patient Safety Quality and Improvement Act of 2005 requires changes such as moving toward an incentive-based system, providing continuing education programs for healthcare providers, and reforming residency programs.

Simulation-Based Medical Error Disclosure Training for Pediatric Healthcare Professionals Karen I. Wayman, Kimberly A. Yaeger, Paul J. Sharek, Sandy Trotter, Lisa Wise, June A. Flora, Louis P. Halamek

Abstract:This pilot study uses a preintervention-postintervention design to investigate the effects of medical error disclosure training in a simulated setting for pediatric oncology nurses. The results of a paired t test showed statistically significant increases in nurses’ communication self-efficacy to carry out medical disclosure.

Reliability and Validity of Hand Hygiene Measures Linda Harrington, Kim Lesh, Lynda Doell, Sandra K. Ward

Abstract: An examination of publications between 1990 and 2006 that address measures of hand hygiene—undoubtedly the most important strategy in combating the debilitating effects of multidrug-resistant organisms in healthcare—indicates that further research is needed to identify reliable and valid measures.

Interview with a Quality Leader: E. Scott Geller on People-Based Healthcare Safety
Susan V. White

Abstract: E. Scott Geller, PhD, is a senior partner of Safety Performance Solutions, Inc., Blacksburg, VA, which specializes in behavior-based safety training and consulting. He addresses the human dynamics of occupational safety.

Interview with a Quality Leader: Tania Daniels on the Minnesota Alliance for Patient Safety
Susan V. White

Abstract: Tania Daniels, MBA PT, is the vice president for patient safety at the Minnesota Hospital Association, St. Paul, MN. She serves as lead staff member for the Minnesota Alliance for Patient Safety, a voluntary coalition of more than 50 healthcare stakeholders.

Medication Reconciliation: Harvard Pilgrim Health Care’s Approach to Improving Outpatient Medication Safety
Lydia Bernstein, Judith Frampton, Neil B. Minkoff, Salpi Stepanian, Lisa Iapicca, Jennifer Rollo, Lana Kodysh, Maureen Kelly, Steven Bucchianeri, Kristy LaGrange

Abstract: Research indicates that the rate of outpatient adverse drug events may be about four times as high as that reported in hospital studies and that more than one third of these events are preventable. Harvard Pilgrim Health Care introduced a medication reconciliation program in an effort to enhance patient safety by improving medication use and safety.

Evaluating Initiatives to Reduce Seclusion and Restraint: A Managerial Perspective on Enhancing Performance Improvement Methodology
Sue Hardesty, Jeffrey J. Borckardt, Rochelle Hanson, Anouk L. Grubaugh, Carla Kmett Danielson, Alok Madan, Benjamin L. Weinstein, Christina R. Hogarth, Christopher Pelic, Janice Hazy, Mary Lou Shoemaker

Abstract: This article presents a model for testing individual elements of a large-scale performance improvement project to reduce the use of seclusion and restraint in a behavioral healthcare organization. Early experiences with this model from a hospital manager’s perspective are discussed, along with the costs and benefits of using it.

JHQ Web Exclusives

q&a: Kathleen Butler on Patient Safety from the Perspective of the Chief Quality Officer
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