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1

Using Health Care Failure Mode and Effect Analysis™: The VA National Center for Patient Safety’s Prospective Risk Analysis System

DeRosier, Joseph, Stalhandske, Erik, Bagian, James P., Nudell, Tina

Journal:

The Joint Commission Journal on Quality Improvement

Year:

2002

Language:

english

File:

PDF, 482 KB

english, 2002

2

Human factors and ergonomics in patient safety curriculum

Linda Williams, Bradley V. Watts, Scott McKnight, James P. Bagian

Journal:

Human Factors and Ergonomics in Manufacturing & Service Industries

Year:

2012

Language:

english

File:

PDF, 248 KB

english, 2012

3

Medical Team Training: Applying Crew Resource Management in the Veterans Health Administration

Dunn, Edward J., Mills, Peter D., Neily, Julia, Crittenden, Michael D., Carmack, Amy L., Bagian, James P.

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 69 KB

english, 2007

4

Patient Safety Solutions Preamble - May 2007

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 257 KB

english, 2007

5

Framework for Alarm Management Process Maturity

Welch, James, Rayo, Michael, Kanter, Benjamin, Bagian, Tandi, Jacobs, Katrina, Shanawani, Hassan, Jaffe, Rory, Conti, Marlyn, Razzano, Lynn

Journal:

Biomedical Instrumentation & Technology

Year:

2016

Language:

english

File:

PDF, 1.70 MB

english, 2016

6

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training

Douglas E. Paull, Lisa M. Mazzia, Brent S. Izu, Julia Neily, Peter D. Mills, James P. Bagian

Journal:

The American Journal of Surgery

Year:

2009

Language:

english

File:

PDF, 274 KB

english, 2009

7

Tactical Combat Casualty Care 2007: Evolving Concepts and Battlefield Experience

Butler, Frank K., Butler, Frank K., Holcomb, John B., Giebner, Stephen D., McSwain, Norman E., Bagian, James

Journal:

Military Medicine

Year:

2007

Language:

english

File:

PDF, 141 KB

english, 2007

8

Association Between Implementation of a Medical Team Training Program and Surgical Mortality

Neily, Julia, Mills, Peter D., Young-Xu, Yinong, Carney, Brian T., West, Priscilla, Berger, David H., Mazzia, Lisa M., Paull, Douglas E., Bagian, James P.

Journal:

JAMA The Journal of the American Medical Association

Year:

2010

Language:

english

File:

PDF, 204 KB

english, 2010

9

The Veterans Affairs Root Cause Analysis System in Action

Bagian, James P., Gosbee, John, Lee, Caryl Z., Williams, Linda, McKnight, Scott D., Mannos, Dea M.

Journal:

The Joint Commission Journal on Quality Improvement

Year:

2002

Language:

english

File:

PDF, 131 KB

english, 2002

10

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork

Sculli, Gary L., Fore, Amanda M., Sine, David M., Paull, Douglas E., Tschannen, Dana, Aebersold, Michelle, Seagull, F. Jacob, Bagian, James P.

Journal:

Journal of Healthcare Risk Management

Year:

2015

Language:

english

File:

PDF, 1.19 MB

english, 2015

11

An Examination of Mortality and Other Adverse Events Related to Electroconvulsive Therapy Using a National Adverse Event Report System

Watts, Bradley V., Groft, Alicia, Bagian, James P., Mills, Peter D.

Journal:

Year:

2011

Language:

english

File:

PDF, 98 KB

english, 2011

12

A Cognitive Aid for Cardiac Arrest: You Can’t Use It if You Don’t Know About It

Mills, Peter D., DeRosier, Joseph M., Neily, Julia, McKnight, Scott D., Weeks, William B., Bagian, James P.

Journal:

The Joint Commission Journal on Quality and Safety

Year:

2004

Language:

english

File:

PDF, 513 KB

english, 2004

13

Using the Six Sigma Process to Implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 Intensive Care Units

Noel E. Eldridge, Susan S. Woods, Robert S. Bonello, Kay Clutter, LeAnn Ellingson, Mary Ann Harris, Barbara K. Livingston, James P. Bagian, Linda H. Danko, Edward J. Dunn, Renee L. Parlier, Cheryl Ped

Journal:

Journal of General Internal Medicine

Year:

2006

Language:

english

File:

PDF, 592 KB

english, 2006

14

The Future of Graduate Medical Education

Bagian, James P.

Journal:

Academic Medicine

Year:

2015

Language:

english

File:

PDF, 267 KB

english, 2015

15

Using Aggregate Root Cause Analysis to Improve Patient Safety

Neily, Julia, Ogrinc, Greg, Mills, Peter, Williams, Rodney, Stalhandske, Erik, Bagian, James, Weeks, William B.

Journal:

The Joint Commission Journal on Quality and Safety

Year:

2003

Language:

english

File:

PDF, 393 KB

english, 2003

16

Patient Identification

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 385 KB

english, 2007

17

Advances in the ACGME Clinical Learning Environment Review (CLER) Program

Weiss, Kevin B., Wagner, Robin, Bagian, James P., Newton, Robin C., Patow, Carl A., Nasca, Thomas J.

Journal:

Journal of Graduate Medical Education

Year:

2013

Language:

english

File:

PDF, 160 KB

english, 2013

18

Patient safety: lessons learned

James P. Bagian

Journal:

Pediatric Radiology

Year:

2006

Language:

english

File:

PDF, 79 KB

english, 2006

19

Response to Tishler and Reiss' review of inpatient suicide

Peter D. Mills, James P. Bagian

Journal:

General Hospital Psychiatry

Year:

2009

Language:

english

File:

PDF, 45 KB

english, 2009

20

Communication During Patient Hand-Overs

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 678 KB

english, 2007

21

Using aggregate root cause analysis to improve patient safety.

Neily, Julia, Ogrinc, Greg, Mills, Peter, Williams, Rodney, Stalhandske, Erik, Bagian, James, Weeks, William B

Journal:

The Joint Commission Journal on Quality and Safety

Year:

2003

Language:

english

File:

PDF, 305 KB

english, 2003

22

Performance of Correct Procedure at Correct Body Site

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 759 KB

english, 2007

23

Challenges and Opportunities in the 6 Focus Areas: CLER National Report of Findings 2018

Weiss, Kevin B., Co, John Patrick T., Bagian, James P.

Journal:

Journal of Graduate Medical Education

Year:

2018

Language:

english

File:

PDF, 166 KB

english, 2018

24

System Innovation: Veterans Health Administration National Center for Patient Safety

Heget, Jeffrey R., Bagian, James P., Lee, Caryl Z., Gosbee, John W.

Journal:

The Joint Commission Journal on Quality Improvement

Year:

2002

Language:

english

File:

PDF, 84 KB

english, 2002

25

Control of Concentrated Electrolyte Solutions

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 269 KB

english, 2007

26

SAE Technical Paper Series [SAE International International Conference On Environmental Systems - (JUL. 09, 1990)] SAE Technical Paper Series - Heart Rate and Pulmonary Function While Wearing the Launch-Entry Crew Escape Suit (LES) During +Gx Acceleration and Simulated Shuttle Launch

Krutz, Robert W., Bagian, James, Burton, Russell R., Meeker, Larry J.

Year:

1990

Language:

english

File:

PDF, 354 KB

english, 1990

27

Response from the Feature Authors

Bagian, James P.

Journal:

Frontiers of Health Services Management

Year:

2005

File:

PDF, 11.98 MB

2005

28

Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety

GERAINT H. LEWIS, RHEMA VAITHIANATHAN, PETER M. HOCKEY, GUY HIRST, JAMES P. BAGIAN

Journal:

Milbank Quarterly

Year:

2011

Language:

english

File:

PDF, 170 KB

english, 2011

29

The Accreditation System After the “Next Accreditation System”

Nasca, Thomas J., Weiss, Kevin B., Bagian, James P., Brigham, Timothy P.

Journal:

Academic Medicine

Year:

2014

Language:

english

File:

PDF, 256 KB

english, 2014

30

Assuring Medication Accuracy at Transitions in Care

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 447 KB

english, 2007

31

Do Older Rural and Urban Veterans Experience Different Rates of Unplanned Readmission to VA and Non-VA Hospitals?

William B. Weeks, Richard E. Lee, Amy E. Wallace, Alan N. West, James P. Bagian

Journal:

The Journal of Rural Health

Year:

2009

Language:

english

File:

PDF, 132 KB

english, 2009

32

Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program

Douglas E. Paull, Lisa M. Mazzia, Scott D. Wood, Max S. Theis, Lori D. Robinson, Brian Carney, Julia Neily, Peter D. Mills, James P. Bagian

Journal:

The American Journal of Surgery

Year:

2010

Language:

english

File:

PDF, 473 KB

english, 2010

33

Health care and patient safety: The failure of traditional approaches – how human factors and ergonomics can and MUST help

James P. Bagian

Journal:

Human Factors and Ergonomics in Manufacturing & Service Industries

Year:

2012

Language:

english

File:

PDF, 228 KB

english, 2012

34

Look-Alike, Sound-Alike Medication Names

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 337 KB

english, 2007

35

Avoiding catheter and Tubing Mis-connections

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 271 KB

english, 2007

36

Medical Team Training Improves Team Performance

Carpenter, James E., Bagian, James P., Snider, Rebecca G., Jeray, Kyle J.

Journal:

The Journal of Bone & Joint Surgery

Year:

2017

Language:

english

File:

PDF, 1.09 MB

english, 2017

37

Search and Rescue Is Search and Rescue—Or, the Basics Still Apply

James P. Bagian

Journal:

Wilderness & Environmental Medicine

Year:

2005

Language:

english

File:

PDF, 52 KB

english, 2005

38

Single Use of Injection Devices

Abdellatif, Ahmed, Bagian, James P., Barajas, Enrique Ruelas, Cohen, Michael, Cousins, Diane, Denham, Charles R., Essinger, Kaj, Gegelashvili, Giorgi, Glenister, Helen, Hoffman, Carolyn, Horvath, Dian

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 254 KB

english, 2007

39

Scenario 10: cold water immersion

Journal:

Wilderness & Environmental Medicine

Year:

1998

Language:

english

File:

PDF, 210 KB

english, 1998

40

Cerebral Blood Flow: Comparison of Ground-Based and Spaceflight Data and Correlation with Space Adaptation Syndrome

Bagian, James P., Hackett, Peter

Journal:

Journal of Clinical Pharmacology

Year:

1991

Language:

english

File:

PDF, 910 KB

english, 1991

41

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery

Gagnier, Joel J., Derosier, Joseph M., Maratt, Joseph D., Hake, Mark E., Bagian, James P.

Journal:

International Journal for Quality in Health Care

Year:

2016

Language:

english

File:

PDF, 289 KB

english, 2016

42

The Overarching Themes From the CLER National Report of Findings 2018

Co, John Patrick T., Bagian, James P., Weiss, Kevin B.

Journal:

Journal of Graduate Medical Education

Year:

2018

File:

PDF, 90 KB

2018

43

Awareness and Use of a Cognitive Aid for Anesthesiology

Neily, Julia, DeRosier, Joseph M., Mills, Peter D., Bishop, Michael J., Weeks, William B., Bagian, James P.

Journal:

The Joint Commission Journal on Quality and Patient Safety

Year:

2007

Language:

english

File:

PDF, 295 KB

english, 2007

44

Using the six sigma process to implement the centers for disease control and prevention guideline for hand hygiene in 4 intensive care units

Noel E. Eldridge, Susan S. Woods, Robert S. Bonello, Kay Clutter, LeAnn Ellingson, Mary Ann Harris, Barbara K. Livingston, James P. Bagian, Linda H. Danko, Edward J. Dunn, Renee L. Parlier, Cheryl Ped

Journal:

Journal of General Internal Medicine

Year:

2006

Language:

english

File:

PDF, 445 KB

english, 2006

45

Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR

Brian T. Carney, Priscilla West, Julia Neily, Peter D. Mills, James P. Bagian

Journal:

Year:

2010

Language:

english

File:

PDF, 210 KB

english, 2010

46

The Role of the Operating Room Nurse Manager in the Successful Implementation of Preoperative Briefings and Postoperative Debriefings in the VHA Medical Team Training Program

Lori D. Robinson, Douglas E. Paull, Lisa M. Mazzia, Lisa Falzetta, James Hay, Julia Neily, Peter D. Mills, Brian Carney, James P. Bagian

Journal:

Journal of PeriAnesthesia Nursing

Year:

2010

Language:

english

File:

PDF, 155 KB

english, 2010

47

Earth observations during space shuttle right STS‐29: Discovery's Voyage to the earth

Lulla, Kamlesh, Helfert, Michael, Whitehead, Victor, Amsbury, David, Coats, Michael, Blaha, John, Buchli, James, Springer, Robert, Bagian, James, Evans, Cindy

Journal:

Geocarto International

Year:

1989

Language:

english

File:

PDF, 2.54 MB

english, 1989

48

Improving Clinical Learning Environments for Tomorrow's Physicians

Nasca, Thomas J., Weiss, Kevin B., Bagian, James P.

Journal:

New England Journal of Medicine

Year:

2014

Language:

english

File:

PDF, 367 KB

english, 2014

49

Reducing Avoidable Deaths Among Veterans: Directing Private-Sector Surgical Care to High-Performance Hospitals

Weeks, William B., West, Alan N., Wallace, Amy E., Lee, Richard E., Goodman, David C., Dimick, Justin B., Bagian, James P.

Journal:

American Journal of Public Health

Year:

2007

Language:

english

File:

PDF, 109 KB

english, 2007

50

Making the Business Case for Patient Safety

Weeks, William B., Bagian, James P.

Journal:

The Joint Commission Journal on Quality and Safety

Year:

2003

Language:

english

File:

PDF, 120 KB

english, 2003

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