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1

P, Uselton John, Coe Charles P, Joint Commission on Accreditation of Healthcare Organizations., and American Society of Health-System Pharmacists., eds. Preparing to meet Joint Commission patient safety goals. American Society of Health-System Pharmacists, 2004.

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Joint Commission on Accreditation of Healthcare Organizations. and Joint Commission Resources Inc, eds. Meeting the Joint Commission's 2009 national patient safety goals. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources, ed. Staff education tools for the National Patient Safety Goals: Curriculum guide and CD-ROM. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources, ed. Handoff communications: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources, ed. Anticoagulation therapy: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources. Hand hygiene: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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7

Inc, Joint Commission Resources, ed. Anticoagulation therapy: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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8

M, Fry Helen, ed. Medication reconciliation: Toolkit for implementing national patient safety goal 8. Joint Commission Resources, 2008.

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9

Inc, Joint Commission Resources, ed. Reducing the risk of patient harm resulting from falls: Toolkit for implementing national patient safety goal 9. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources, ed. Reducing the risk of patient harm resulting from falls: Toolkit for implementing national patient safety goal 9. Joint Commission Resources, 2008.

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Inc, Joint Commission Resources, ed. Reducing the risk of patient harm resulting from falls: Toolkit for implementing national patient safety goal 9. Joint Commission Resources, 2008.

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12

M, Fry Helen, ed. Do-not-use abbreviations: Toolkit for implementing national patient safety goal 2B. Joint Commission Resources, 2008.

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13

Patton, Kurt A. Anticoagulant therapy FAQs: A guide to compliance with national patient safety goal 3E. HCPro, 2008.

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14

Patton, Kurt A. Anticoagulant therapy FAQs: A guide to compliance with national patient safety goal 3E. HCPro, 2008.

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15

Patton, Kurt A. Anticoagulant therapy FAQs: A guide to compliance with national patient safety goal 3E. HCPro, 2008.

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16

(Firm), HCPro. Suicide risk assessment FAQs: A guide to compliance with national patient safety goal 15.01.01. HCPro, 2008.

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17

Meeting the international patient safety goals. Joint Commision International, 2007.

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18

Bud, REHS and Patton, Kurt Pate. The 2009 National Patient Safety Goals FAQs. HCPro, Inc, 2008.

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19

Joint Commission. 2007 National Patient Safety Goals for Hospitals. Joint Commission Resources, 2006.

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20

Jcaho. 2006 National Patient Safety Goals for Hospital Posters:. Joint Commission Resources, 2006.

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21

Jcaho. Staff Education Tools for the National Patient Safety Goals. Joint Commission Resources, 2007.

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22

Braithwaite, Jeffrey, and Liam Donaldson. Patient Safety and Quality. Edited by Ewan Ferlie, Kathleen Montgomery, and Anne Reff Pedersen. Oxford University Press, 2016. http://dx.doi.org/10.1093/oxfordhb/9780198705109.013.16.

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Over the last 25 years we have learned how providers can fall short of their goals, and deliver care which is below expectations. In response, nations and the international community including the World Health Organization have developed strategies to tackle harm and improve the quality of care. Key approaches include strengthening management and leadership; designing improvement tools, models and approaches; enhancing teamwork, communication and local cultures; and leveraging opinion leaders and champions. A shift towards a systems perspective, factoring in the challenges of complexity and ne
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23

Consultants, Thomson American Health. Tips, Tools, And Techniques For Meeting Your Patient Safety Goals. American Health Consultants, 2004.

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24

Paugh, Jennifer. National Patient Safety Goals Calculator, 2007: Tools to Assess Compliance, the. HCPro, Inc., 2006.

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25

JCR. Meeting the Joint Commission's 2006 National Patient Safety Goals CD-ROM. JCR Publications, 2006.

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26

The JCAHO 2005 National Patient Safety Goals (Successful Strategies for Compliance). HCPro, Inc., 2004.

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27

Krasker, Glenn D., and Della M. Lin. The Jcaho 2003 National Patient Safety Goals: Successful Strategies for Compliance. Hcpro Inc, 2003.

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28

The National Patient Safety Goals Calculator, 2006: Tools to Assess Compliance. HCPro, 2005.

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29

Robb, Fiona, and Andrew Seaton. What are the principles and goals of antimicrobial stewardship? Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198758792.003.0002.

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Antimicrobial stewardship (AS) is a coordinated strategy for quality improvement designed to improve the appropriate use of antimicrobial agents to optimize clinical outcomes whilst minimizing collateral antimicrobial effects including antimicrobial resistance andClostridium difficileinfection. AS is a function of the multidisciplinary antimicrobial management team and is dependent on key relationships with infection protection and control, clinical governance, therapeutic, and medical management structures within a healthcare organization. AS should operate within a national framework and is
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30

Jcr. Patients as Partners: Toolkit for Implementing National Patient Safety Goal 13. Not Avail, 2007.

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31

Lachman, Peter, Jane Runnacles, Anita Jayadev, John Brennan, and John Fitzsimons, eds. Oxford Professional Practice: Handbook of Patient Safety. Oxford University Press, 2022. http://dx.doi.org/10.1093/med/9780192846877.001.0001.

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The World Health Organisation has designated 2020 to 2030 as the decade of patient safety. An action plan has been developed specifying what is required to happen to achieve the goal of zero patient harm worldwide. In many countries patient safety is now a priority, as we develop new processes of care. In this handbook, the theories underlying patient safety science are presented and then applied to different clinical areas in an easy-to-follow manner. The theories and methods of human factors and ergonomics, reliability theory, management of risk and investigation of adverse events, building
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32

Tahseen, Muhammad, and Richard L. Simmons. Evolution and Evidence for Rapid Response Teams (DRAFT). Edited by Raghavan Murugan and Joseph M. Darby. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190612474.003.0001.

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A rapid response system (RRS) is a program designed to respond in a timely, organized, and comprehensive manner to a patient’s urgent unmet medical need within a healthcare facility. The goals of the rapid response team (RRT) are to restore homeostasis, prevent further physiologic deterioration, and establish an optimal environment of care. RRTs are now in widespread use in the US because of the Joint Commission’s national patient safety goals, which required that healthcare organizations improve recognition and response to changes in a patient’s condition. Recent meta-analyses have now conclu
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33

Grech, Dennis, and Laurence M. Hausman. Anesthetic Techniques. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190495756.003.0004.

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Anesthetic techniques for procedures performed outside the traditional operating room are varied. General anesthesia, sedation, and regional anesthesia can all be delivered in this venue. The choice of technique is based on safety considerations and patient comorbidities. Perioperative monitoring such as pulse oximetry, end-tidal carbon dioxide monitoring, and electrocardiography and blood pressure monitoring protocols must be consistent with American Society of Anesthesiologists guidelines. Common procedures include elective office-based anesthetics, emergency room sedations, endoscopic retro
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34

Anticoagulation therapy: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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35

Anticoagulation therapy: Toolkit for implementing the national patient safety goal. Joint Commission Resources, 2008.

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36

Suicide prevention: Toolkit for implementing national patient safety goal 15A. Joint Commission Resources, 2007.

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37

Marano, Christopher M. Driving Considerations in Cognitive Impairment and Depression in Older Patients. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199959549.003.0008.

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Cognitive impairment can impair driving skills and safety, and given the fact that persons with MCI can develop cognitive deficits in several cognitive domains it is important to address driving safety. The goal of the clinician is to identify potentially unsafe drivers without unnecessarily restricting safe drivers, and this chapter focuses on evaluating patients in this gray area. The office exam can be be broadened to address cognitive and functional assessments that may reflect on driving safety, and the clinician may advise the patient and family to have a comprehensive driving assessment
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38

Vydyanathan, Amaresh, Naum Shaparin, Allan L. Brook, and Samer N. Narouze. Lumbar Transforaminal/Nerve Root Injections: Computed Tomography. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199908004.003.0018.

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This chapter discusses the accuracy and safety of lumbar transforaminal or nerve root (periradicular) injections under CT guidance. To maximize procedure accuracy and minimize complications, spinal injections are best performed with image guidance. Though fluoroscopic guidance has been used for decades, greater accuracy and possibly greater safety can be achieved with CT guidance. The radiation exposure is operator dependent, and maintaining the lowest possible dose is critical in optimizing patient care. This is also true for fluoroscopic guidance, for which coning and intermittent exposure a
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39

Reducing the risk of patient harm resulting from falls: Toolkit for implementing national patient safety goal 9. Joint Commission Resources, 2008.

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40

Roth, Katalin. Bioethical Issues in Integrative Geriatrics. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190466268.003.0030.

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Many older persons use complementary and alternative medicine (CAM), and an integrative approach is very consistent with the holistic model of geriatric “slow medicine.” Ethical practice requires an understanding of the patient’s values and goals of care. The core ethical principles of beneficence, autonomy, and justice are applied to geriatric concerns such as decision-making capacity, prognosis, and advance care planning. Informed consent requires that patients understand the goals of treatment, conventional options, and the evidence and safety of CAM therapies. Legal issues affecting CAM pr
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41

Gulliford, Martin, and Edmund Jessop, eds. Healthcare Public Health. Oxford University Press, 2020. http://dx.doi.org/10.1093/oso/9780198837206.001.0001.

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Healthcare public health is concerned with the application of population sciences to the design, organization, and delivery of healthcare services, with the ultimate aim of improving population health. This book provides a modern introduction to the methods and subject matter of healthcare public health, bringing together coverage of all the key areas in a single volume. Topics include healthcare needs’ assessment; access to healthcare; knowledge management; ethical issues; involvement of patients and the public; population screening; health promotion and disease prevention; new service models
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42

Whaley, Natalie S., and Adam Evans. Pregnancy Safety and Termination. Edited by Emma Ciafaloni, Cheryl Bushnell, and Loralei L. Thornburg. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190667351.003.0002.

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Access to compassionate, nonjudgmental, and safe abortion care for medically complex women is an important component of obstetric care for high-risk women. The care of women with neurologic disease who seek pregnancy termination or management of pregnancy failure includes consideration of their particular medical, anesthesia, and surgical needs. Counseling regarding pregnancy options is an important first step in helping women achieve their family planning goals. Understanding the safety of abortion, as well as options for medical, surgical, or labor induction termination can help providers di
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43

Price, Julie R., Alric D. Hawkins, and Steven D. Passik. Opioid therapy: managing risks of abuse, addiction, and diversion. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0095.

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Given the complex and chronic medical problems that are seen in the palliative care setting, there is an ever increasing need for awareness of prescription drug abuse. Providers must balance the potential for abuse of prescribed opioids with the need to provide appropriate analgesia for patients in the palliative care setting. In addition, the presence of aberrant drug use amongst patients with advanced illness represents a major impediment to appropriate care. In order to maximize patient outcomes and to prescribe needed medication both safely and fairly, the clinician should work to develop
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44

Mowll, Charles. Patient Safety Pocket Guide: Safe Care Practices and Communication Tools for Patient Care Teams Seeking the High Reliability Goal of Harm-Free Healthcare. Patient Safety Coaches Academy, 2022.

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45

Mowll, Charles. Patient Safety Pocket Guide: Safe Care Practices and Communication Tools for Patient Care Teams Seeking the High Reliability Goal of Harm-Free Healthcare. Patient Safety Coaches Academy, 2022.

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46

Riskin, Loren, and Alex Macario. Complex Systems and Approaches to Quality Improvement. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199366149.003.0010.

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This chapter, “Complex Systems and Approaches to Quality Improvement,” serves as an introduction to complex systems management and current thinking in improvement science. It explains the context behind quality improvement (QI) initiatives, beginning with a discussion of the ultimate goals of this movement. It then briefly reviews the history of QI development and early leaders in the field. The universal elements of a successful QI or patient safety project are discussed, followed by the exploration of commonly encountered barriers to systems and individual improvement. The chapter also highl
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47

Ebm, Claudia, and Andrew Rhodes. Post-operative fluid and circulatory management in the ICU. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0363.

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Fluid and circulatory management is an integral part of the peri-operative care of critically-ill patients. Precisely estimating the volumetric needs of post-operative patients remains difficult. While the majority of patients tolerate intra-operative fluid loss easily, patients with reduced physiological reserve present more of a challenge. Targeting specific physiological goals and optimizing haemodynamics with fluids and inotropes, means outcomes of these patients can be improved. This approach is often referred as goal-directed therapy (GDT). ‘Individualized goal-directed therapy’ can vary
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48

Weaver, Bradley D., and Randy L. Jensen. Hemangiopericytoma. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190696696.003.0012.

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Hemangiopericytoma (HPC) represents a rare, diagnostically challenging tumor for neurosurgical oncologists. Often, HPC appears as a dural-based, extra-axial mass lacking the characteristic hyperostosis and calcification of meningioma. Rapidly growing unconfirmed meningioma-like masses warrant increased suspicion of HPC. These tumors differ significantly from meningiomas in natural history and implications for patient morbidity and mortality. Histopathological analysis is required for proper diagnosis. MRI with and without contrast is recommended for operative planning, and angiography and preo
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49

Dyer, Robert A., Michelle J. Arcache, and Eldrid Langesaeter. The aetiology and management of hypotension during spinal anaesthesia for caesarean delivery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713333.003.0023.

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The management of hypotension during spinal anaesthesia for caesarean delivery remains a challenge for anaesthesiologists. Close control of maternal haemodynamics is of great importance for maternal and fetal safety, as well as maternal comfort. Haemodynamic responses to spinal anaesthesia are influenced by aortocaval compression, the baricity and dose of local anaesthetic and opioid employed, the rational use of fluids, and the goal-directed use of vasopressors. The most common response to spinal anaesthesia is hypotension and an increased heart rate, which reflects a decreased systemic vascu
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50

Watkins, Scott C., Christopher L. Cropsey, and Cory M. Furse. Teamwork and Crisis Resource Management. Edited by Matthew D. McEvoy and Cory M. Furse. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190226459.003.0002.

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By definition, a team is two or more people who are working together. Teamwork can be thought of as the dynamic behaviors, cognitions, attitudes, and skills that allow a team to perform its stated goal. Concerning healthcare teamwork, nearly two decades ago, the Institute of Medicine issued the report To Err Is Human, which identified teamwork as a key target for improving the quality and safety of patient care. Over the last twenty-five years, crisis resource management has become synonymous with a style of teamwork and performance epitomized by healthcare providers in high acuity, time-press
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