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Health Updates on the Web
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The Patient Safety Group has compiled the latest in health, quality, and safety, news and reports.
AHRQ Innovations Exchange
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals
Aug-27-2014
This guide provides recommendations to help hospitals address unique patient needs, meet patient-centered communication standards, and comply with related Joint Commission requirements.
Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients
Aug-27-2014
Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.
Connecting Those at Risk to Care: A Guide To Building a Community "HUB" To Promote a System of Collaboration, Accountability, and Improved Outcomes
Aug-27-2014
This guide is intended to help improve the system by which at-risk individuals within a community are identified and connected to appropriate health care and social services.
Health Information Privacy and Security: A 10 Step Plan
Aug-27-2014
Health Information Privacy and Security: A 10 Step Plan provides health care providers and organizations with practical tips on how to protect patient information in electronic health records.
IMPaCT™ Model Tool Kit
Aug-27-2014
The IMPaCT™ model is an evidence-based system for community health worker recruitment, training, and care. This toolkit is designed to help other organizations adapt and implement this model. 
Low-Overhead Medical Home Leverages Information Technology To Attract Both Providers and Patients in Underserved Rural Areas
Aug-27-2014
A low-overhead medical home leverages information technology to produce a financially viable, high-quality primary care experience that proves to be attractive to both physicians and patients in an underserved rural area.
Oral Health Risk Assessment Tool
Aug-27-2014
The Oral Health Risk Assessment (OHRA) Tool helps pediatricians and other medical providers understand risk factors, protective factors, and clinical findings related to dental caries in young children and is accompanied by a family guide to better oral health.
Patient Centered Medical Home Resource Center
Aug-27-2014
The Patient Centered Medical Home Resource Center provides policymakers and researchers with access to evidence-based resources about the medical home and its potential to transform primary care and improve the quality, safety, efficiency, and effectiveness of U.S. health care.

AHRQ WEBMM
SPOTLIGHT CASE AND COMMENTARY: Pitfalls in Diagnosing Necrotizing Fasciitis
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.
CASE AND COMMENTARY: Liver Biopsy: Proceed With Caution
Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.
CASE AND COMMENTARY: Benefits vs. Risks of Intraosseous Vascular Access
During a code blue, an intraosseous line was placed in the left tibia of an elderly woman after several unsuccessful attempts to obtain peripheral venous access. Following chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit. A few hours later, the left leg was dusky purple with sluggish distal pulses.
In Conversation with...Urmimala Sarkar, MD, MPH
Dr. Sarkar is an associate professor of medicine at UCSF whose research has focused on ambulatory patient safety, including missed and delayed diagnosis, adverse drug events, and monitoring failures for outpatients with chronic diseases. We spoke with her about patient safety in the ambulatory setting.
Beyond the Hospital: the New Frontier of Patient Safety
This piece describes the new landscape of patient safety in outpatient care, including elements adapted from hospital settings and the growing evidence base for ambulatory-specific efforts.

BLOG
Crowdsourcing My New Book on How Computerization is Changing the Practice of Medicine in Surprising Ways
Jun-16-2014
I have been in blog-silence mode of late, for which I am sorry. Rumors that I’ve taken my Elton John act on the road are, I’m pleased to assure you, incorrect. Instead, I’ve been hard at work on my new book, tentatively titled “Disrupted: Hope, Hype and Harm at the Dawn of Medicine’s Digital Age.” […]
Hospitalist Potpourri
Apr-14-2014
I’m just back from the annual meeting of the Society of Hospital Medicine and, as usual, I was blown away. I’ve not seen a medical society meeting that is remotely like it. As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the […]
Patient Safety’s First Scandal: The Sad Case of Chuck Denham, CareFusion, and the NQF
Jan-30-2014
In retrospect – always in retrospect – it should have been obvious that, when it came to Dr. Charles Denham, something was not quite right. In a remarkable number of cases of medical errors, it’s clear – again, in retrospect – that there were signs that something was amiss, but they were ignored. The reasons […]
Global Health Hospitalists: Strange but Noble Bedfellows
Dec-19-2013
As my Division of Hospital Medicine has grown – now to about 60 faculty – I spend part of my time figuring out what direction we should go in. At times, the path is obvious. It didn’t take Wayne Gretsky to recognize that we needed expertise in healthcare IT a decade ago, or in cost […]



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