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1
Curriculum Vitae
Date Prepared: January 27, 2016
Name: Tejal Kanti Gandhi
Office Address: National Patient Safety Foundation
268 Summer Street
6th floor
Boston, MA 02210
Home Address: 16 Bess Rd
Needham, MA 02492
Work Phone: 617-391-9904
Work Email: [email protected]
Place of Birth: Queens, New York
Education
1989 B.A. Magna cum laude Biochemistry Cornell University, Ithaca,
NY
1994
M.D. Harvard Medical School,
Boston, MA
1999 M.P.H. Clinical Effectiveness Harvard School of Public
Health, Boston, MA
Postdoctoral Training
06/94-06/95 Intern Internal Medicine Duke University Medical
Center, Durham, NC
06/95-06/97 Resident Internal Medicine Duke University Medical
Center
07/97-06/99 Fellow General Medicine Brigham and Women's
Hospital, Boston, MA
Faculty Academic Appointments
1999-2004 Instructor Medicine Harvard Medical School,
Boston, MA
2004-2009 Assistant Professor Medicine Harvard Medical School,
Boston, MA
2009- Associate Professor Medicine Harvard Medical School,
Boston, MA
2
01/97-12/99 Physician Medicine Salem Hospital, Salem,
MA
07/97-
present
Associate Physician Division of General Medicine Brigham and Women's
Hospital
2012 - Instructor (non-faculty) Center for Continuing Prof Dev HSPH, Boston, MA
Major Administrative Leadership Positions
Local
2000-2007 Director of Patient Safety Brigham and Women's Hospital
2004-2007 Assistant Director Partners Patient Safety
Signature Initiative
Partners
2004-
present
Director of Medicine Housestaff Rotation in
Patient Safety
Brigham and Women's Hospital
2005 Director of Patient Safety Course Harvard Medical School
2005 Site Director of Patient Safety for HMS 1
students
Harvard Medical School
2007- Chair, Partners High Performance Medicine
Team 2: Patient Safety
Partners
2007-2010 Executive Director of Quality and Safety Brigham and Women's Hospital
2008-2009 Director of Patient Safety (part-time) Partners
2010-2011 Director of Patient Safety (full-time) Partners
2011-2013 Chief Quality and Safety Officer Partners
2013 - President, National Patient Safety
Foundation
NPSF
2013 - President, Lucian Leape Institute NPSF
2013 - President, Certified Board of Professionals
in Patient Safety
CBPPS
2014 –
President and CEO, National Patient Safety
Foundation
NPSF
Regional
National and International
2010- Faculty Institute for Healthcare Improvement
Cambridge, MA
Committee Service
Local
1998-2000 Ambulatory Medicine Quality Improvement
Project Research Committee
Brigham and Women's Hospital
Member
1998-2000 PHO Information Systems Committee Brigham and Women's Hospital
Member
3
1999-2000 Patient Safety Committee Brigham and Women's Hospital
Member
1999-2001 Ambulatory Care Advisory Group Brigham and Women's Hospital
Member
2000-2009 Care Improvement Council Brigham and Women's Hospital
Member
2000-2005 Patient Safety Integration Group/RiSC
Committee
Brigham and Women's Hospital
Chairperson
2000 Medication Use Process Improvement
Committee
Brigham and Women's Hospital
Member
2000-2004 Pharmacy and Therapeutics Committee Brigham and Women's Hospital
Member
2000-2005 Drug Safety Committee Brigham and Women's Hospital
Chairperson
2000-2007 Quality Assurance/Risk Management
Committee
Brigham and Women's Hospital
Member
2001-2007 Patient Safety Advisory Group Harvard Risk Management Foundation
Member
2001-2007 Patient Safety Leaders Partners
Member
2002-2003 Medication Services Steering Committee Partners
Member
2003-2004 Next Generation Order Entry Advisory
Committee
Partners
Member
2003-2005 PCHI Outpatient Drug Management
Committee
Partners, Needham, MA
Member
2003-2007 Decision Support Subcommittee (Patient
Safety Signature Initiative)
Partners
Member
2004-2007 Patient Safety Signature Initiative Partners
Sub Team Leader
2006-2009 Quality Outcomes Group Brigham and Women's Hospital
Member
2006-2010 Medication Reconciliation Steering
Committee
Partners
Business owner/executive sponsor
2007-2010 Partners High Performance Medicine Team
2
Partners
Chairperson
2007-2013 Patient Safety Leaders Partners
Chairperson
2008-2009 Ambulatory Quality and Safety Committee Brigham and Women’s Hospital
Co-chair
4
2008-2009 Hospital P4P Committee Partners
Member
2008-2013 Board/Operations Committee Harvard Risk Management Foundation
Member
2009- P4P Infrastructure/Technology Committee Partners
Member
2009 Ambulatory Risk Management Leaders CRICO/RMF
Member
2010- 2013 Readmissions HPM 4 Initiative Partners
Chairperson
2010-2013 LMR Clinical Content Committee Partners
Member
2010-2013 Palliative Care HPM Initiative Partners
Chairperson
2010-2012 Common Clinical Systems Assessment
Committee
Partners
Member
2011-2012 CRICO/RMF CEO Search Committee CRICO
Member
Regional
2001-2002 Initiative to Reduce Ambulatory Medical
Errors
Massachusetts Coalition for Preventing
Medical Errors, Burlington, MA
Member
2002-2003 Communicating Panic Lab Values Massachusetts Coalition for Preventing
Medical Errors, Boston, MA
2002-2013 Mass Coalition for Preventing Medical
Errors Committee
Massachusetts Coalition for Preventing
Medical Errors, Burlington, MA
Member
2004-2005 Application Review Team for Merck
Fellowships
Institute for Healthcare Improvement,
Boston, MA
Member
2015- Advisory Board Betsy Lehman Center, Boston MA
Member
National and International
1993-1994 Residency Curriculum Committee Duke University Medical Center, Durham,
NC
Member
2000 Abstract Committee Society of General Internal Medicine
National Meeting, Boston, MA
Member
5
2001 Advisory Panel WebM&M, San Francisco, CA
Member
2002-2003 Safety Climate Study University of Colorado, Denver, CO
Member
2003-2004 Patient Safety Working Group American Board of Medical Specialties,
Chicago, IL
Member
2004 Medication Errors Databases Research
Advisory Group
U.S. Pharmacopeia, Rockville, MD
Member
2004 Technical Expert Panel JCAHO, Chicago, IL
Member
2004-2006 Advisory Board Maryland Patient Safety Center, Baltimore,
MD
Member
2005 Health Information Technology and Patient
Safety Track
Annual AHRQ Patient Safety Meeting,
Washington, DC
Member
2005 Abstract Committee
Society of General Internal Medicine
National Meeting, New Orleans, LA
Member
2005 National Advisory Committee for Physician
Practice Patient Safety Assessment
Health Research and Education Trust,
Medical Group Management,
Member
2006 JCAHO Medication Safety Expert Panel Joint Commission for Hospital
Accreditation, Chicago, IL
Member
2006-2007 Delphi Panel, Prioritizing Patient Safety
Outcome Measures
RAND Corporation, California
Member
2006-2007 Action Steering Committee HBC, Chicago, IL
Member
2009-2010 HAC/SRE Steering Group National Quality Forum, Washington, DC
Member
2009-2010 CDS Expert Panel National Quality Forum, Washington, DC
Member
2009-2010 Meaningful Use Expert Advisory Board CITL, Partners Healthcare, Boston, MA
Member
2010-2012 University of Toronto Centre for Patient
Safety Advisory Board
University of Toronto, Toronto, Canada
Member
2011-2013 National Patient Safety Foundation Board of Governors, Boston, MA
Member
6
2011 SRE Taskforce National Quality Forum, Washington, DC
Member
2011 SRE Ambulatory Technical Advisory Panel National Quality Forum, Washington, DC
Chair
2011 MITSS Leadership Committee Member
2011-2012 NPSF Annual Congress Planning
Committee
Member
2012 Medication Measures Technical Expert
Panel
CMS/FMQAI, Tampa, FL
Member
2012 National Estimates of Ambulatory Safety
Technical Expert Panel
Dept. Health and Human Services,
Washington, DC
Member
2012- Advisory Board
VA Patient Safety Center of Inquiry on
Measurement
VA Patient Safety Center of Inquiry on
Measurement, Boston, MA
Member
2013 Quality Advisory Group Wockhardt Hospitals/Partners Harvard
Medical International, Mumbai, India
Member
2013-2014 Maintenance and Development of
Medication Measure Special Innovation
Project
CMS
Member
2013-2104 CMS Technical Expert Panel CMS/FMQAI, Tampa, FL
Member
2013 Expert Advisory Panel
CCHIT HIT/ACO Framework, Chicago, IL
Member
2013 ONC Expert Panel
Use of Health IT to Reduce Adverse Events
ONC, Teleconference
Member
2013 Dissemination and Implementation of CER
Findings
PCORI Roundtable, Washington, DC
Member
2013- Patient Safety Advisory Group Joint Commission, Chicago, IL
Member
2014-
2014
Healthcare Safety Hotline
Technical Expert Panel
Premier Advisory Panel
RAND/AHRQ/Washington DC
Member
Premier, Charlotte, NC
Member
2014 NQF Readmission Action Team NQF, Washington, DC
Member
2014 ONC FACA HIT Safety Task Force ONC, Washington, DC
Member
7
2014 AMIA EHR-2020 Task Force AMIA, Bethesda, MD
Member
2014 CMS Technical Expert Panel on HAC
Measures
CMS
Member
2014- Leapfrog Group Expert Panel on Barcoding Leapfrog Group
Chair
2014 - ECRI Partnership for Health IT Safety
Advisory Panel
ECRI
Member
2014- NQF Expert Panel (Prioritization and
Identification of Health IT Patient Safety
Measures)
NQF, Washington, DC
Member
2014 -2015 ONC Implementation, Safety, and Usability
Workgroup
ONC, Washington, DC
Member
2014 - 2015 RTI Health IT Safety Center
RoadmapTaskforce
RTI
Member
2014 National Estimates of Ambulatory Safety
Technical Expert Panel
Member
2015- John. Q. Sherman Award Committee Standard Register
Member
2015- AHRQ PSNet Technical Expert Panel AHRQ
Member
2015- Surveys on Patient Safety Culture Technical
Expert Panel
AHRQ
Member
2015 AHRQ Report on Ambulatory Patient
Safety Practices
AHRQ
Key Informant
2015 Quality and Patient Safety Awards
Selection Committee
Kaiser Permanente
Member
2015 Hearst Health Prize Award Committee Hearst Health/Jefferson
Member
2015 Pew Foundation Usability Meeting Pew Foundation
Advisory Committee Member
2015- Patient Safety Learning Lab Steering Brigham and Women’s Hospital
Committee Member
2015 15 Years After To Err is Human expert panel NPSF, Boston, MA
Member
2015 RCA Best Practice Core Group NPSF, Boston, MA
2015 ASHP Commission on Goals ASHP, Bethesda, MD
Member
2015 ECRI Partnership Copy and Paste Subgroup ECRI Partnership
Chair
2015 Health IT Patient Safety Technical Expert
Panel
AHRQ
Member
8
2016 Health IT Safety Collaborative: Usability
and Medication Management Work Group:
RTI International
Member
2016 Planning Committee to advance the
development and application of clinical
decision support
NAM/ONC
Member
Professional Societies
1996-2000 American College of Physicians
Associate, Philadelphia, PA
1997-2010 Society of General Internal Medicine
Member, Washington, DC
1998- American Medical Informatics Association
Member, Washington, DC
1998-2001 American Medical Association
Member, Chicago, IL
1999- Massachusetts Medical Society
Member, Waltham, MA
2011- American Society of Professionals in
Patient Safety
Member, Boston, MA
2013 - Certified Professional in Patient Safety
Member, Boston, MA
Grant Review Activities
2004-2008 Grant Application Review Team Harvard Risk Management Foundation
Member Harvard Risk Management
Foundation
2010 ONC Beacon Communities Grant Review
Committee
Washington, DC
Panel Chair
Other Editorial Roles
2011-2014 UpToDate Section Editor of Quality and
Safety
UpToDate
Waltham, MA
2012- American Journal of Medical Quality Editorial Board
Philadelphia, PA
9
Honors and Prizes
1989 Phi Beta Kappa Cornell University Academic performance
1992-1993 Howard Hughes
Research Fellow
N.I.H. Research
1993-1994 Howard Hughes
Fellowship Award
N.I.H. Research excellence
2000 Partners in Excellence
Award
Partners Medication Use Process
Improvement Team
2000 Latiolais Leadership
Grant
Ohio State University Research
2001 Second Place in Poster
Competition
2001 AMIA National Meeting Research
2001 Partners in Excellence
Award
Partners Drug Safety Committee
2001 Partners in Excellence
Award
Partners Medication Use/Barcoding
Team
2002 Partners in Excellence
Award
Partners LMR Reminders Team
2003 Partners in Excellence
Award
Partners LMR Prescribing Decision
Support Team
2004 Partners in Excellence
Award
Partners RL Solutions Team
2005 Donabedian Award American Public Health
Association
Career achievement
2006 Partners in Excellence
Award
Partners Nursing Barcode
Satisfaction Team
2006 Partners in Excellence
Award
Partners Medication Reconciliation
Team
2006 Partners in Excellence
Award
Partners Black Box Team
2009 John Eisenberg Quality
and Safety Award
National Quality Forum/The Joint
Commission
Individual Research
Accomplishment
2008 Brigham Leadership
Program
Harvard Business School
2011 Value in Healthcare
Course
Harvard Business School
2011 Partners in Excellence
Award
Partners Patient Safety Leaders
Committee
2012 Partners in Excellence
Award
Partners End of Life Dashboard
10
2014 Modern Healthcare Top 100 Most Influential People in Healthcare
2015 Modern Healthcare 50 Most Influential Physicians in Healthcare
2015 Modern Healthcare Top 25 Women in Healthcare
2015 Modern Healthcare Top 100 Most Influential People in Healthcare
2015 AMIA Leadership Award
Report of Funded and Unfunded Projects
Past
1999-2000 Ambulatory Medicine Quality Improvement Project, Harvard Risk Management
Foundation
Foundation: research funding
Co-investigator
Understand rates of medication related symptoms in the ambulatory setting
1999-2001 Improving Medication Prescribing, Harvard Risk Management Foundation
Foundation: research funding
Co-P.I.
Understand the rates of adverse drug events and medication errors in the ambulatory
setting
1999-2001 Outpatient Chemotherapy Errors, Harvard Risk Management Foundation
Foundation: research funding
Co-P.I.
Understand the rates of medication errors and adverse drug events in the ambulatory
chemotherapy setting
2000 Latiolais Leadership Grant
Foundation: career development
Co-P.I.
Improving Medication Prescribing
Understand the rates of adverse drug events and medication errors in the ambulatory
setting
2000-2003 Improving Quality with Outpatient Decision Support
N.I.H./RO1 HS11046-02
P.I.
Measure the impact of electronic reminders and results management systems on quality
and safety in the ambulatory setting
2000-2003 Improving Safety with Computerized Outpatient Prescribing
N.I.H./RO1 HS11169-01
Co-P.I.
Create and implement an adverse drug event monitor in outpatient settings, and measure
the impact of basic and advanced electronic prescribing on ADEs and medication errors
11
2001-2004 Medical Insurers' Medical Error Prevention Study
N.I.H./RO1 HS 11886-01
Co-investigator
Analyze malpractice claims to understand the etiology of missed and delayed diagnosis
errors in the ambulatory setting
2001-2005 New York Commonwealth Fund
Foundation: research funding; Grant #:20010373
P.I.
Computerizing Outpatient Referrals
Develop and electronic referral tool in an ambulatory EMR and measure its impact on
referral communication
2002-2007 Shared Online Health Records for Patient Safety Care
N.I.H./RO1 HS13326-01
Co-investigator
Understand the impact of a patient portal on patient reporting of adverse drug events and
the accuracy of outpatient medication lists.
2003-2004 The Effect of Results Management Systems at Post-Discharge, Harvard Risk Management
Foundation
Foundation: research funding; number
P.I.
Describe the epidemiology of tests pending after hospital discharge and develop an
electronic intervention
2003-2006 Using Barcode Technology to Improve Medication Safety
N.I.H./RO1 HS 14053-02
P.I.
Measure the impact of barcode technology on medication errors, workflow, and
satisfaction
2004-2008 Improving Quality and Safety with Outpatient Order Entry
N.I.H., RO1 HS 1015226
P.I.
Measure the impact of outpatient order entry (actionable reminders, order tracking) on
ambulatory quality and safety
2006-2007 Electronic Prescribing Using a Common Utility: the E-prescribing Gateway
N.I.H., R01 HS 016377-01
Co-Investigator
Understand key aspects for successful implementation of e-prescribing
2007-2008 Preventing Errors Introduced by the Use of Electronic Prescribing, Harvard Risk
Management Foundation
Foundation: research funding
Co-Investigator
Identify errors introduced by the use of electronic prescribing
2007-2008 Improving Physician Awareness of and Communication About Hospital Readmissions,
Harvard Risk Management Foundation
Foundation: research funding
Co-Investigator
Understand the rates of physician awareness of hospital readmission, and identify possible
solutions
12
2007-2010 Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD)
N.I.H./5RO1HL089755-02
Co-Investigator ($1,000,000)
The major goal is to use a pharmacist intervention to reduce the incidence of serious
medication errors during the first 30 days after hospital discharge among cardiac patients.
My role is to assist with study design and methodology as an expert in the field, as well as
perform adverse event determinations and assist with critical revision of manuscripts.
2007-2011 CERT-Health Information Technology and Improving Medication Use (Projects 3 and 4)
Agency for Healthcare Research and Quality, 1U18 HS106970-01
Co-Investigator ($4,000,000)
Project 3: The major goal is to characterize unintended consequences of electronic
prescribing and identify prevention opportunities. My role is to serve as an adjudicator of
adverse events and unintended consequences and assist with critical revision of
manuscripts.
Project 4: The major goal is to evaluate the impact of post-discharge medication
reconciliation on adverse events after discharge. My role is to assist with design of the
intervention, study design, adverse event determinations, and critical revision of
manuscripts.
2008-2009 Harvard Risk Management Foundation Linking Test Ordering with Order Tracking
Foundation: research funding
Co-P.I. ($45,000)
The major goal is to develop and study an intervention that detects when tests are ordered
but not completed, and then sends letters to patients to increase completion rates. My role
is to oversee the entire project, timeline, and budget, as well as study design and
methodology.
2008-2009 Harvard Risk Management Foundation Closing the Loop on Diagnosis Error at BWH
Foundation: research funding
Co-P.I. ( $45,000)
The major goal is to develop ways to better identify diagnosis errors and to create M&M
conferences that better discuss these types of errors. My role is to facilitate coordination
with hospital risk management and patient safety efforts, and assist with case identification
as well as methodology.
2010-2012 Improving Management of Outpatient Actionable Test Results Agency for Healthcare Research and Quality, 1 R18 HS019603-01
Co-Investigator
The major goal is to study the impact of standardized policies around clinically significant
test result communication on follow-up of these test results.
2010-2012 Deployment of Enhanced Critical Imaging Result Notification (DECIRN) Agency for Healthcare Research and Quality, 1 R18 HS019635-01
Co-Investigator
The major goal is to study the impact of an electronic radiology test result notification
application on test result communication and follow-up.
2011-2012 Spread of ANCR
CRICO
PI ($1M)
The major goal is to study the spread of a novel test result notification tool across Partners
13
2011-2014 HMS Fellowship in Quality and Safety.
CRICO
PI ($3M)
The major goal is the development and implementation of a new fellowship in quality and
safety.
2014-2015 Creating Best Practices for Root Cause Analysis
The Doctors Company Foundation
PI ($150K)
The major goal is the development of a standardized process and toolset that providers are
now using to ensure that their root cause analyses are undertaken in keeping with best
practices and the most current thinking
Current
2014- Spread of Communication and Resolution Programs
Beth Daley Ullem Foundation
PI ($100K)
The major goal is to create best practices for educating leadership about CRP programs.
2015 To Err Is Human 15 yrs later
AIG
PI ($250K)
The major goal is to assess the state of the patient safety field and set the stage for the next
15 years of work
2016- Safety Culture Playbook for Leadership
American College of Healthcare Executives
PI ($280K)
The major goal is the creation of a Patient Safety Culture “Playbook” with operational
tactics for Healthcare Executives to drive safety culture change
2016- RCA Webcast Series
The Doctors Company Foundation
PI ($52K)
The major goal is to implement an educational webcast series based on the RCA best
practices document released by NPSF in 2015.
Report of Local Teaching and Training
Teaching of Students in Courses
1992-1994 Patient Doctor II - Physical Diagnosis
course
Harvard Medical School
5 medical students 2 hrs per wk for 27 wks
1998 Primary Care Clerkship Harvard Medical School
12 Medical Students 20 hrs per yr for 1 yr
1998 Critical Appraisal of the Literature Harvard Medical School
8 Medical Students 2 hrs per wk for 27 wks
1998-2000 Patient Doctor Interviewing course Harvard Medical School
7 Medical Students 2 hrs per wk for 27 weeks
1998-2000 Patient Doctor II - OSCE Harvard Medical School
15 Medical Students 4 hrs per yr for 1 yr
14
2000 Introduction to Clinical Medicine (HST) Harvard Medical School
40 Medical Students 1 hr per yr for 1 yr
2002 Patient Safety course Harvard Medical School
40 Medical Students 1 hr per yr for 1 yr
2004 Patient Doctor III - Patient Safety course Harvard Medical School
30 Medical Students 1 hr per yr for 1 yr
2004- Clinical Effectiveness Informatics course Harvard School of Public Health
30 Graduate Students 1 hr per yr for 1 yr
2005 Patient Safety for HMS 1 students Harvard Medical School
25 Medical Students 1 hr per yr for 1 yr
2007 HMS Health Policy Class Harvard Medical School
25 Medical Students 1 hr per yr for 1 yr
2010 Quality and Safety Case Discussion Harvard Medical School
25 Medical Students 1 hr per year for 1 yr
2010 High Performance Medicine Course Harvard School of Public Health
25 HSPH Students 2 hr per year for 1 year
2011 HMS Subinternship Harvard Medical School
10-15 subinterns/year 3 hrs 2x/year
2011 Patient Doctor III Intersession Harvard Medical School
40 HMS students 1 hr per year for 1 yr
2012 Patient Doctor III Intersession Leader Harvard Medical School
160 HMS students 3 hrs per year for 1 yr
2014 Introduction to Patient Safety Harvard Medical School
20 Medical students 1 hr per year for 1 yr
2015 Health Information Technology and Patient
Safety - Health in the 21st Century
50 students
Harvard T Chan School of Public Health for
Universidad Andrés Bell
1 hr per year for 1 yr
Formal Teaching of Residents, Clinical Fellows and Research Fellows
1998-2000 Critical Appraisal of the Literature Brigham and Women’s Hospital
7 Residents 8 hrs per yr for 1 yr
2000 Lectures on Patient Safety Brigham and Women’s Hospital
25 Residents 8 hrs per yr for 1 yr
2004-2009 Medicine Housestaff Rotation in Patient
Safety
Brigham and Women’s Hospital
5 Residents/year 2 week rotations
2008-2011 Co-Director, Center of Expertise in Quality
and Safety for Partners Residents and
Fellows
Partners
2010-2012 Internal Medicine Management Leadership
Track
Brigham and Women’s Hospital
Shadowing
2011-2014 HMS Fellowship in Quality and Safety HMS
Fellowship Director
2014 – HMS Fellowship in Quality and Safety HMS
Fellowship Advisor 50 hrs per yr (lectures, mentoring, advising)
2015 Quality Rounds Massachusetts General Hospital
15
Clinical Supervisory and Training Responsibilities
1997-2001 Clinic Preceptor/ Brigham Internal
Medicine Associates/Brigham and
Women’s Hospital
60 hrs per yr
1999-2010 Supervising research fellows/ Brigham and
Women's Hospital
50 hrs per yr
1999-2012 Ward attending/ Brigham and Women's
Hospital
120 hrs per yr
2011-2014 Fellowship Director/HMS Fellowship in
Quality and Safety
Formally Supervised Trainees and Faculty
2001-2003 Eric Poon, MD/ Assistant Professor (Brigham and Women's Hospital)
Supervised his fellowship research projects and also subsequent research performed as
junior faculty; career mentoring as well; resulted in publications of manuscripts
2002-2004 Tom Sequist, MD/Assistant Professor (Brigham and Women's Hospital)
Supervised his fellowship research projects and also subsequent research performed as
junior faculty; career mentoring as well; resulted in publications of manuscripts
2003-2005 Nidhi Shah, MD/ Assistant Professor (New Haven Medical Center)
Supervised her fellowship research projects and career mentoring as well; resulted in
publications of manuscripts
2004- Allen Kachalia, MD / Assistant Professor
Career mentoring as well as supervision of research projects resulting in publication
2005-2007 Michael Matheny, MD / Fellow (Brigham and Women's Hospital)
Supervised his fellowship research projects and career mentoring as well; resulted in
publications of manuscripts
2007-2009 Rob El-Kareh, MD/ Fellow
Supervised his fellowship research projects and career mentoring as well; resulted in
publications of manuscripts
2007-2009 Lydia Siegel, MD / Fellow
Supervised her fellowship research projects and career mentoring as well
Formal Teaching of Peers
2000 Reducing Medication Error in Outpatient Settings:
Physicians and Pharmacists Working Together
1 hr contact per yr
Boston, MA
CRICO/RMF
2004 The Patient Safety Imperative CME course:
"Ambulatory Patient Safety"
1 hr contact per yr
Boston, MA
Harvard Medical School
2006-2007 The Patient Safety Imperative CME course:
"Executive Patient Safety WalkRounds"
1 hr contact per yr
Boston, MA
Harvard Medical School
2008-
The Patient Safety Imperative CME course:
“Creating a Patient Safety Program”
1 hr contact per yr
Boston, MA
Harvard Medical School
16
2009-2010 Update in Hospital Medicine CME course
“Creating a Patient Safety Program”
1 hr contact/yr
Boston, MA
Harvard Medical School
2010-2014
IHI Patient Safety Officer CME course
“Ambulatory Patient Safety: Risks and Opportunities”
2 hr contact/yr
Cambridge, MA
Institute for Healthcare Improvement
2010, 2011 Office Practice of Primary Care Medicine CME
“Ambulatory Patient Safety”
1.5 hr contact/yr
Boston, MA
Harvard Medical School
2011 Leadership Strategies for Information Technology in
Health Care “Experimentation matters: using research
and operations to improve patient safety”
1.5 contact/yr
Boston, MA
Harvard School of Public Health
2011 Update in Hospital Medicine CME course
“Patient Safety Cases”
1 hr contact/yr
Boston, MA
Harvard Medical School
2012, 2014 Leadership Strategies for Information Technology in Health
Care Co-director 30 hrs/yr
Boston, MA
Harvard School of Public Health
2012 IHI Patient Safety Officer CME course
“HIT and Patient Safety
Cambridge, MA
2012 Masters in Health Care Mgmt QI Course
“Creating Safe Systems: From Theory to Practice” 3 hrs/yr
Boston, MA
2013-
Lecturer
Harvard School of Public Health
NPSF Lucian Leape Institute Forum
30 hrs/yr
Boston, MA
2014-
2014-2015
NPSF Annual Congress Planning Committee Chair
(Orlando, Austin, Scottsdale)
IHI's Patient Safety Executive Development Program
“Patient Safety Across the Continuum”
Institute for Healthcare Improvement
100 hrs/yr
2 hr contract/yr
Cambridge, MA
Harvard School of Public Health
2015
2015
2015
Update in Hospital Medicine CME course
“Using IT to improve Patient Safety”
Leadership Strategies for Information Tech HSPH
“Using IT to improve Patient Safety”
HMS SQIL course (Safety, Quality, Informatics)
“The Changing Landscape of Patient Safety”
1 hr contact/yr
Boston, MA
2 hrs contact/yr
1 hr/year
Boston, MA
Local Invited Presentations
2001 Orthopedics M&M case review and analysis/Lecturer
Brigham and Women's Hospital
2001 Dangerous places: patients, families, and hospital staff striving for patient safety/Lecturer
Beth Israel Deaconess Medical Center (West)
2002 Development of a Patient Safety Program/Lecturer
Harvard School of Public Health
17
2002 A Systems Approach to Error/Lecturer
Brigham and Women's Hospital
2002 Disclosure of Medical Error/Lecturer
BWH Ethics Conference, Brigham and Women's Hospital
2002 BWH Patient Safety Program/Lecturer
Risk Management Foundation Law Day, Cambridge, MA
2003 Creating an Integrated Patient Safety Program/Lecturer
Harvard School of Public Health/Price-Waterhouse Coopers
2003 A Systems Approach to Error/Lecturer
Internal Medicine Morbidity and Mortality Conference, Brigham and Women's Hospital
2004 A Systems Approach to Error: Curriculum Design/Lecturer
Partners Residency Program Directors
2007 Improving Hospital Medication Safety/Lecturer
Faulkner Hospital Board of Directors Meeting
2008 Practical approaches to ambulatory medication safety/Lecturer
Faulkner Hospital Grand Rounds
2009 Medication Safety Priorities/Lecturer
Massachusetts General Hospital Fellows Retreat
2010 Medical Errors in the Outpatient Setting/Lecturer
Partners Physicians Day
2010 Missed and Delayed Diagnosis in the Outpatient Setting/Lecturer
Harvard Risk Management Foundation Education Session
2010 Quality and Safety for Hospitalists/Lecturer
Lahey Clinic Hospitalist M&M conference
2010 Introduction to Patient Safety
Partners Healthcare Leadership Course
2010 LMR Research Summary
CIRD Informatics Research Seminar
2013 Patient Safety Across the Continuum of Care/Lecturer
MGH Ambulatory Safety Conference
2013 Changing Landscape of Patient Safety/Lecturer
Harvard Medical School Intersession
2014 Patient Safety Across the Continuum of Care/Lecturer
Mongan Institute for Health Policy Faculty Meeting
2014 Diagnostic Errors: Why Focus on Them?/Lecturer
Massachusetts General Hospital Forum
2014 The Changing Landscape of Patient Safety/Lecturer
Faulkner Hospital Grand Rounds
2014 The Changing Landscape of Patient Safety/Lecturer
MGH Anesthesia Grand Rounds
2014 The Changing Landscape of Patient Safety/Lecturer
2015
Brigham and Women’s Hospital Course in Patient Safety
The Changing Landscape of Patient Safety/Keynote Speaker
Massachusetts General Hospital annual poster symposium
18
Report of Regional, National and International Invited Teaching and Presentations
Invited Presentations and Courses
Regional
1999 "Medication Safety: Are We Doing Enough?"/Grand Rounds
Holy Family Hospital, Methuen, MA
2000 "Medication Errors and Potential Adverse Drug Events Among Outpatients"/Invited
Lecturer
Annual Meeting Special Scientific Symposium, Society of General Internal Medicine,
Boston, MA
2000 "Can Physician Order Entry Really Eliminate Medication Errors; and How Can I Afford
It?"/Invited Lecturer
Conference: Medication Error Reduction, VHA Conference, Providence, RI
2003 Conference: Promoting safety in child and adolescent health care/Expert Discussant
Agency for Healthcare Research and Quality/Commonwealth Fund, Cambridge, MA
2004 "Safe practices for medication safety and communicating critical test results for physician
offices/ambulatory care"/Invited Lecturer
Massachusetts Medical Society, Waltham, MA
2004 "Implementing technology to improve patient safety"/Invited Lecturer
NPSF Annual Meeting, Boston, MA
2004 "Quest for Quality Award Winner Presentation"/Invited Lecturer
NPSF Annual Meeting, Boston, MA
2007 "Missed and delayed diagnosis in ambulatory care"/Other
RMF Symposium, Boston, MA
2007 "Introduction to Patient Safety"/Invited Lecturer
Boston Medflight 2007 Critical Care Transport Conference
2007 "Introduction to Patient Safety"/ Other
Boston Medflight staff meeting, Lincoln, MA
2010 “Ambulatory Patient Safety: Risks and Opportunities”/Grand Rounds Invited Lecturer
Emerson Hospital, Concord, MA
2012 “Ambulatory Patient Safety: Risks and Opportunities”
Harvard University Health System Grand Rounds, Cambridge, MA
2012 “Integrated Health Care”
Advanced Leadership Think Tank, Harvard Business School, Cambridge, MA
2012 “Improving Medication Safety with Information Technology”
Leonard Morse Hospital Grand Rounds, Natick, MA
2012 “Improving Medication Safety with Information Technology”
Metrowest/Framingham Union Grand Rounds, Framingham, MA
2012 “Improving Patient Safety with Information Technology”
Children’s Hospital Informatics Conference, Boston, MA
2013 “Patient Safety Across the Continuum of Care”
IHI Patient Safety Executive Development Program Presentation, Boston, MA
MAHQ Annual Meeting and Program, Westborough, MA
2014 “Through the Eyes of the Workforce: Creating Joy, Meaning, and Safety Health Care”
Standard Register Healthcare Advisory Council Meeting, Boston, MA
2014 “The Changing Landscape of Patient Safety”/Lecturer
Boston Medical Center 2014 Cogan Lecture, Boston, MA
19
2014 The Changing Landscape of Patient Safety/Lecturer
Mass Coalition for the Prevention of Medical Errors
2015 “The Changing Landscape of Patient Safety”/Lecturer
McLean Hospital Grand Rounds, Belmont, MA
2015 “Quality and Patient Safety in End-of-Life Care”/Lecturer
Palliative Care of Hospitals and Internists (PCFHI), Boston, MA
2015 Shining a Light: Transparency to Improve Patient Safety/Lecturer
Massachusetts Coalition for Prevention of Errors, Burlington, MA
2015 Five New and Emerging Areas in Patient Safety/Invited lecturer
Harvard Medical School SQIL webinar
National
1997 "Fever and Tick Bite in North Carolina"/Lecturer
Duke University Medical Center, Durham, NC
1997 "Syphilis"/Lecturer
Duke University Medical Center, Durham, NC
1999 "Clinical Alerting Systems for Health Care Decision Support" / Panel Discussant
American Medical Informatics Association Annual Meeting, Washington DC
2000 "Top Priority Actions for Preventing Medication Errors"/Invited Lecturer
PHICO medication errors program, PHICO, Indianapolis, IN
2000 "Reducing Medical Error with Information Systems"/Invited Lecturer
AMDIS Annual Meeting, Ojai, CA
2000 "Can Physician Order Entry Really Eliminate Medication Errors; and How Can I Afford
It?"/Invited Lecturer
Conference: Medication Error Reduction, VHA, Atlanta, GA
2000 "Taxonomy and Nomenclature"/Speaker and Participant
Veterans Administration Adverse Drug Event Working Group, Washington, DC
2000 "Automation and Patient Safety"/Speaker and Participant
American Society of Health-system Pharmacists Annual Meeting, Las Vegas, NV
2001 "A Systems Approach to Medication Errors"/Invited Lecturer
Michigan Pharmacists Association Annual Convention, Dearborn, MI
2001 "Impact of Basic Computerized Prescribing on Outpatient Medication Errors and Adverse
Drug Events"/ Plenary Presentation
Society of General Internal Medicine Annual Meeting, San Diego, CA
2001 "Reducing Medication Errors through a Computerized Physician Order Entry
System"/Invited Lecturer
JCAHO 2001 National Conference: Promoting Quality and Safety Across the Healthcare
Continuum, Chicago, IL
2001 "Patient Safety and Information Technology at Brigham and Women's Hospital"/Theater-
style demonstration
2002 "Patient Safety and Information Technology"/Invited Lecturer
Scottsdale Institute Annual Seminar, Scottsdale, AZ
2002 "Medical Errors and Patient Safety in Cardiology"/Invited Lecturer
AHA 4th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular
Disease, Washington DC
2003 "Using Electronic Medical Records to Identify Adverse Events" / Invited Lecturer
AHRQ Symposium: Tools and Methods for Monitoring Patient Safety, Washington, DC
20
2003 "Practical strategies for implementing NQF best practices"/Breakout session
National Quality Forum, Los Angeles, CA
2003 "Decision Support Systems for TRIP"/Invited Lecturer
AHRQ TRIP conference, Washington, DC
2003 "Outpatient Medication Safety /Invited Lecturer
SOS Rx Coalition Meeting, Washington, DC
2003 "Partners Outpatient Applications"/Theater-style presentation
AMIA Annual Meeting, Washington, DC
2003 "Outpatient Patient Safety" / Tutorial Presentation
AMIA Annual Meeting, Washington, DC
2004 "Patient Safety in Radiology”/Invited Lecturer
RSNA Annual Meeting, Chicago, IL
2004 "Using Information Technology to Improve Safety and Quality in the Ambulatory Setting"
/ Precourse discussant
SGIM Conference, Chicago, IL
2004 Quality IT Workgroup Teleconference/Expert discussant
Centers for Medicare Services (CMS), National Teleconference
2004 "Fumbled Handoffs” /Invited Lecturer
Management of the Hospitalized Patient conference, San Francisco, CA
2004 Precourse: Ambulatory Medication Safety/Precourse discussant
Medinfo conference, San Francisco, CA
2004 "Creating a Hospital Patient Safety Program"/Invited Lecturer
Management of the Hospitalized Patient conference, San Francisco, CA
2004 "Risk Management and Patient Safety"/Invited Lecturer
AHRQ Safety Conference, Washington, DC
2005 "Improving Patient Safety in Ambulatory Care"/Invited Lecturer
Annual Conference of San Diego Patient Safety Center, San Diego, CA
2005 "Practical Strategies to Improve Ambulatory Patient Safety"/Invited Lecturer
Annual Meeting, National Patient Safety Foundation, Orlando, FL
2005 "Patient Safety Research in Ambulatory Care"/Invited Lecturer
Annual Meeting, National Patient Safety Foundation, Orlando, FL
2005 "Using Information Technology to Reduce ADEs"/Invited Lecturer
Annual AHRQ Patient Safety Meeting, Washington, DC
2006 "Enlisting Leadership and Staff Buy-In for Barcode Technology"/Invited Lecturer
AMIA Annual Meeting, Washington, DC
2007 "Ambulatory Decision Support"/Other
AMIA Annual Meeting, Chicago, IL
2007 "Using Decision Support to Improve Medication Use"/Other
AHRQ, Annual HIT meeting, Bethesda, MD
2007 "Lessons Learned in Clinical Decision Support" / Other
AHRQ, Annual HIT meeting, Bethesda, MD
2009 “Improving medication safety using information technology”/Invited Lecturer
Mayo Clinic Quality and Safety Forum, Rochester, MN
2010 “Improving medication safety using information technology”/Invited Lecturer
American Association of Professionals from India Annual Mtg, Washington DC
2010 “Clinical and Operations Pearls”/Invited Lecturer
National Quality Forum Webinar
21
2010 “Using HIT to prevent adverse events”/Invited Lecturer
AHRQ Webinar
2011 “Ambulatory Patient Safety: risks and opportunities”/Invited Lecturer
IHI International Summit on Improving Patient Care in the Office Practice, Dallas, TX
2011 “Patient Safety and HIT”/Invited Lecturer
NPSF Annual Board Meeting, Washington DC
2011 “Ambulatory Patient Safety: risks and opportunities”
Brown Medical School Patient Safety Conference, Providence RI
2012 “Ambulatory Patient Safety: Risks and Opportunities”
Mount Sinai Medical Center Grand Rounds, NY, NY
2012 “Leveraging HIT to Improve Quality/Safety”
University of Chicago Grand Rounds, Chicago, IL
2012 “Ambulatory Patient Safety Opportunities”
IHI Outpatient Summit, Washington DC
2012 “Creating a Culture of Safety in the Outpatient Setting”
2012
IHI Outpatient Summit, Washington DC
“HIT and Medication Safety”
IHI Webinar- Preventing ADEs Expedition
2013 “Combining Patient Safety Research and Operations”
Vanderbilt University Quality Leaders Council, Nashville, TN
2013 “Using HIT to Improve Patient Safety”
NPSF Annual Meeting, New Orleans, LA
2013 “The Changing Landscape of Patient Safety”
AHA Leadership Summit, San Diego, CA
2013 “Ambulatory Patient Safety: Risks and Opportunities”
TMIT High Performer Webinar - Ambulatory Patient Safety Issues – Opportunities for
Improvement
2013 “Patient Safety Across the Continuum of Care”
Penn State Grand Rounds, Hershey, PA
2013 “Patient Safety Across the Continuum of Care”
AAMI Conference, Herndon, VA
2013 “Patient Safety Across the Continuum of Care”
North Shore-LIJ Health System Grand Rounds, Great Neck, NY
2013 “The Changing Landscape of Patient Safety”
National Workshop on Quality for Medical Education, Baltimore, MD
2013 “Patient Safety Across the Continuum of Care”
NYU School of Medicine Grand Rounds, New York, NY
2013 “Patient Safety Across the Continuum of Care”
IHI National Forum, Orlando, FL
2014 “Preparing the Next Generation of Doctors for 21st Century Practice: Optimizing the
Clinical Learning Environment to Meet the Needs of an Evolving Delivery System”
ACGME Pathways Launch, Washington, DC
2014 “Connected Health, Better Adherence”
NEHI Policy Roundtable, Washington, DC
2014 “The Changing Landscape of Patient Safety”
2014 CHA Patient Safety Summit, Wallingford, CT
2014 “The Changing Landscape of Patient Safety”
Kaiser Permanente 5th Annual Patient Safety University, San Diego, CA
22
2014 “The Changing Landscape of Patient Safety”
UMKC School of Medicine Patient Safety Day, Kansas City, MO
2014 “Focus on Diagnostic Errors: Understanding and Prevention”
Tregde Patient Safety Conference, Bronx, NY
2014 “The Changing Landscape of Patient Safety” /Invited Lecturer
Modern Healthcare Patient Safety & Quality Virtual Conference
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer, Presenter
AMIA The Changing Landscape of Patient Safety Webinar
2014 Expert testimony on ambulatory safety
HELP Subcommittee on Primary Health & Aging Congressional Hearing, Washington,
DC
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
Coverys Midwest Risk Management Seminar, Kalamazoo, MI
2014 “Diagnostic Error in Medicine”/Invited Lecturer
Institute of Medicine Diagnostic Error Committee
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
LifePoint CMO and Physician Leaders Meeting, Boston, MA
2014 “Patient Engagement and Patient Safety”/Invited Lecturer
McKesson Leadership Summit, Washington, DC
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
Maine Patient Safety Academy, Portland, ME
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
Association for Vascular Access, National Harbor, MD
2014 Stakeholder Panel/Moderator
ECRI Partnership for Promoting Health IT Patient Safety, Philadelphia, PA
2014 “NPSF Across the Continuum”/Invited Lecturer
American Hospital Association Fellows Meeting, Chicago, IL
2014 “Innovations to Enhance Quality and Outcomes”/Panelist
Scottsdale Institute 13th Annual Fall Forum, Celebration, FL
2014 “Practicing Excellence”/Invited Presenter
Advancing Physician Excellence Podcast
2014 “Strategies for Fast Improvement in American Healthcare”/Panelist
Leapfrog Annual Meeting, Arlington, VA
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
Bipartisan Policy Center Promoting Innovation, Washington, DC
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
VHHA 4th Annual Virginia Patient Safety Summit, Richmond, VA
2015 “The Role of e-Prescribing in Health IT Safety: Challenges and Solutions”
Webinar/Panelist
ONC Health IT Safety Webinar Series
2015 “The Role of e-Prescribing in Health IT Safety: Challenges and Solutions”
Michigan Hospital Association, Detroit, MI
2015 “Front-line Views on Interoperability and Improved Patient Care”/Invited Panelist
WestHealth, Washington, DC
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
Duke 10th Annual Patient Safety Conference, Durham, NC
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
Cassat 18th Annual Symposium, Malvern PA
23
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
AAMI annual meeting, Denver CO
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
Tennessee Hospital Association, Sandestin, FL
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
FSMB webinar, Washington DC
2015 Reactor Panel Participant
Pew Usability Meeting, Washington DC
2015 “The Role of Physicians in Improving Patient Safety”/Invited Panelist
American Board of Medical Specialties annual conference, Chicago
2015 “The Changing Landscape of Diagnostic Safety”/Invited Lecturer
Society to Improve Diagnosis in Medicine Diagnostic Error in Medicine conference
2015 “The Changing Landscape of Patient Safety”/Invited Lecturer
VHA Upper Midwest: Improvement Leaders Network conference, Bloomington MN
2015
“The Changing Landscape of Patient Safety”/Grand Rounds /Invited Lecturer
Beaumont Hospital, Royal Oak, MI
“The Changing Landscape of Patient Safety”/Invited Lecturer
HQI Annual Conference, Sacramento CA
International
2001 "Patient Safety Issues in Health Care"/Invited Lecturer
Brazilian Conference on Medication Systems: Strategies to Reduce Errors and Adverse
Events, University of Sao Paulo at Riberao Preto, College of Nursing, Ribeirao Preto,
Brazil
2002 "Implementing an Integrated Patient Safety Program"/Invited Lecturer
McMaster University Medical Center, Hamilton, Ontario, Canada
2003 "Identification of Outpatient Adverse Drug Events Using a Computer Monitor"/Invited
Lecturer
Society of General Internal Medicine, Vancouver, Canada
2003 "Concepts of Patient Safety" / Invited Lecturer
Practi-Med Dubai, Harvard Medical International, Dubai, UAE
2003 "Creating a Hospital Patient Safety Program: Putting Patient Safety into Action”/Invited
Lecturer
Practi-Med Dubai, Harvard Medical International, Dubai, UAE
2004 "Detection and Prevention of Medication Errors"/Invited Lecturer
Italian Society of Hospital Pharmacists Conference on Error Prevention, Milan, Italy
2009 “Using Information Technology to Improve Medication Safety”/Invited Lecturer
University of Toronto Patient Safety Day, Toronto, Canada
2010 “Introduction to Patient Safety Principles”/Invited Lecturer
Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
2010 “Improving Medication Safety with Information Technology”/Invited Lecturer
Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
2010 “Ambulatory Patient Safety: Risks and Opportunities”/Invited Lecturer
Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
2010 “Creating a Patient Safety Program”/Invited Lecturer
Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
24
2011 “Creating a Culture of Patient Safety”/Invited Lecturer
Hamad Medical Corporation Quality Retreat, Doha, Qatar
2012 “Using Medication Technology to Improve Patient Safety”/Invited Lecturer
Harvard School of Public Health Visiting Chilean delegation
2013 “Using Medication Technology to Improve Patient Safety”/Invited Lecturer
Harvard School of Public Health Visiting Chilean delegation
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
5th International Symposium on Patient Safety, Cali, Colombia
2014 “Improving Hospital Medication Safety Using Information Technology”/Invited Lecturer
5th International Symposium on Patient Safety, Cali, Colombia
2014 “Patient Safety Across the Continuum of Care”/Invited Lecturer
International Society for Quality in Healthcare (ISQua) Annual Conference, Rio de
Janeiro, Brazil
2014 “The Changing Landscape of Patient Safety”/Invited Lecturer
Instituto Argentino de Diagnosicoy Tratamiento (IADT), Buenos Aires, Argentina
2015 Information Technology and Patient Safety / Invited Lecturer
Ministry of Health conference, Montevideo, Uruguay
2015 “The Changing Landscape of Patient Safety” / Invited Lecturer
National Resources Found Workshop, Montevideo, Uruguay
2015 Workforce Safety and Development as a Precondition to Patient Safety / Invited Lecturer
Buenos Aires, Argentina
Report of Clinical Activities and Innovations
Current Licensure and Certification
1997 Massachusetts Registered Physician
2007 Board Certification in Internal Medicine
Practice Activities
1997-
2007
Adult ambulatory outpatient
practice
Internal Brigham and
Women's Hospital, Brigham
Internal Medicine Associates
10-14 patients per week
1997-
2012
Inpatient ward attending Brigham and Women’s
Hospital General Medicine
Service
2-4 weeks per year
Clinical Innovations
I am an important leader in ambulatory patient safety given my numerous important contributions in this
area. Specifically, I have done extensive work on evaluating the incidence and preventability of adverse
drug events in the outpatient setting. I was the lead author of a landmark study published in 2003 that
identified the epidemiology of adverse drug events in outpatients. Furthermore, I have done ground-
breaking work to better understand the epidemiology of other ambulatory safety concerns such as test
result follow-up, missed and delayed diagnosis, transitions of care, and referral communication, and have
drawn attention to the wide variety of safety concerns in the outpatient setting. These projects have been
crucial to highlight the scope and breadth of ambulatory safety issues, to improve our understanding of
the epidemiology of these events, and to then focus on prevention.
25
Report of Technological and Other Scientific Innovations
Development and evaluation of electronic prescribing alerts in the Partners
Longitudinal Medical Record (LMR)
Development and evaluation of the Results Manager application in LMR
Development and evaluation of health maintenance, chronic disease, and
medication monitoring reminders in LMR
Development and evaluation of a medication module in Partners Patient Gateway
Development and evaluation of the referrals module in LMR
Evaluation of the Brigham and Women’s Hospital barcoding/electronic medication
administration record system
Development and evaluation of a Partners electronic medication reconciliation tool
Report of Education of Patients and Service to the Community
Educational Material for Patients and the Lay Community
Patient educational material
2009 We Care About Your Safety brochure Brigham and Women’s Hospital
Report of Scholarship
Peer reviewed publications in print or other media
1. Sittig DF, Gandhi TK, Franklin M, Turetsky M, Sussman AJ, Fairchild DG, Bates DW,
Komaroff AL, Teich JM. A computer-based outpatient clinical referral system. Int J Med Inform.
1999;55(2):149-58.
2. Carpenter CF, Gandhi TK, Kong LK, Corey GR, Chen SM, Walker DH, Dumler JS,
Breitschwerdt E, Hegarty B, Sexton DJ. The incidence of ehrlichial and rickettsial infection in
patients with unexplained fever and recent history of tick bite in central North Carolina. J Infect
Dis. 1999;180(3):900-3.
3. Gandhi TK, Burstin HR, Cook EF, Puopolo AL, Haas JS, Brennan TA, Bates DW. Drug
complications in outpatients. J Gen Intern Med. 2000;15(3):149-54.
4. Gandhi TK, Puopolo AL, Dasse P, Haas JS, Burstin HR, Cook EF, Brennan TA. Obstacles to
collaborative quality improvement: the case of ambulatory general medical care. Int J Qual Health
Care. 2000;12(2):115-23.
5. Leape LL, Kabcenell AI, Gandhi TK, Carver P, Nolan TW, Berwick DM. Reducing adverse drug
events: lessons from a breakthrough series collaborative. Jt Comm J Qual Improv.
2000;26(6):321-31.
26
6. Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication
breakdown in the outpatient referral process. J Gen Intern Med. 2000;15(9):626-31.
7. Gandhi TK, Cook EF, Puopolo AL, Burstin HR, Haas JS, Brennan TA. Inconsistent report cards:
assessing the comparability of various measures of the quality of ambulatory care. Med Care.
2002;40(2):155-65.
8. Rothschild JM, Federico FA, Gandhi TK, Kaushal R, Williams DH, Bates DW. Analysis of
medication-related malpractice claims: causes, preventability, and costs. Arch Intern Med.
2002;162(21):2414-20.
9. Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Patient Safety
Executive Walkrounds. Jt Comm J Qual Saf. 2003;29(1):16-26.
10. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse
events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-7.
11. Silverman JB, Stapinski CD, Churchill WW, Neppl C, Bates DW, Gandhi TK. Multifaceted
approach to reducing preventable adverse drug events. Am J Health Syst Pharm. 2003;60(6):582-
6.
12. Hope C, Overhage JM, Seger A, Teal E, Mills V, Fiskio J, Gandhi TK, Bates DW, Murray MD.
A tiered approach is more cost effective than traditional pharmacist-based review for classifying
computer-detected signals as adverse drug events. J Biomed Inform. 2003;36(1-2):92-8.
13. Poon EG, Wang SJ, Gandhi TK, Bates DW, Kuperman GJ. Design and implementation of a
comprehensive outpatient Results Manager. J Biomed Inform. 2003;36(1-2):80-91.
14. Gandhi TK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E, Seger DL, Shu K, Federico
F, Leape LL, Bates DW. Adverse drug events in ambulatory care. N Engl J Med.
2003;348(16):1556-64.
15. Gandhi TK, Graydon-Baker E, Barnes JN, Neppl C, Stapinski C, Silverman J, Churchill W,
Johnson P, Gustafson M. Creating an integrated patient safety team. Jt Comm J Qual Saf.
2003;29(8):383-90.
16. Murff HJ, Gandhi TK, Karson AK, Mort EA, Poon EG, Wang SJ, Fairchild DG, Bates DW.
Primary care physician attitudes concerning follow-up of abnormal test results and ambulatory
decision support systems. Int J Med Inform. 2003;71(2-3):137-49.
17. Frankel A, Gandhi TK, Bates DW. Improving patient safety across a large integrated health care
delivery system. Int J Qual Health Care. 2003;15 Suppl 1:i31-40.
18. Silverman J, Stapinski C, Huber C, Gandhi, TK, Churchill W. Computer-based system for
prevening adverse drug events. Am J Health-Syst Pharm. 2004;61:1599-603.
19. Roth EM, Christian CK, Gustafson M, Sheridan TB, Dwyer K, Gandhi, TK, Zinner J, Dierks
MM. Using field observations as a tool for discovery: Analysing cognitive and collaborative
demands in the operating room. Cogn Tech Work. 2004;6:148-57.
20. Poon EG, Haas JS, Louise Puopolo A, Gandhi TK, Burdick E, Bates DW, Brennan TA.
Communication factors in the follow-up of abnormal mammograms. J Gen Intern Med.
2004;19(4):316-23.
21. Keating NL, Gandhi TK, Orav EJ, Bates DW, Ayanian JZ. Patient characteristics and
experiences associated with trust in specialist physicians. Arch Intern Med. 2004;164(9):1015-20.
22. Morimoto T, Gandhi TK, Fiskio JM, Seger AC, So JW, Cook EF, Fukui T, Bates DW.
Development and validation of a clinical prediction rule for angiotensin-converting enzyme
inhibitor-induced cough. J Gen Intern Med. 2004;19(6):684-91.
23. Aaronson DW, Gandhi TK. Incorrect allergy injections: allergists' experiences and
recommendations for prevention. J Allergy Clin Immunol. 2004;113(6):1117-21.
27
24. Morimoto T, Gandhi TK, Fiskio JM, Seger AC, So JW, Cook EF, Fukui T, Bates DW. An
evaluation of risk factors for adverse drug events associated with angiotensin-converting enzyme
inhibitors. J Eval Clin Pract. 2004;10(4):499-509.
25. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. "I wish I had seen this test
result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern
Med. 2004;164(20):2223-8.
26. Hsieh TC, Kuperman GJ, Jaggi T, Hojnowski-Diaz P, Fiskio J, Williams DH, Bates DW, Gandhi
TK. Characteristics and consequences of drug allergy alert overrides in a computerized physician
order entry system. J Am Med Inform Assoc. 2004;11(6):482-91.
27. Persell SD, Heiman HL, Weingart SN, Burdick E, Borus JS, Murff HJ, Bates DW, Gandhi TK.
Understanding of drug indications by ambulatory care patients. Am J Health Syst Pharm.
2004;61(23):2523-7.
28. Solomon DH, Brookhart MA, Gandhi TK, Karson A, Gharib S, Orav EJ, Shaykevich S, Licari A,
Cabral D, Bates DW. Non-adherence with osteoporosis practice guidelines: a multilevel analysis
of patient, physician, and practice setting characteristics. Am J Med. 2004;117(12):919-24.
29. Weingart SN, Gandhi TK, Seger AC, Seger DL, Borus J, Burdick E, Leape LL, Bates DW.
Patient-reported medication symptoms in primary care. Arch Intern Med. 2005;165(2):234-40.
30. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring
following hospital discharge. J Gen Intern Med. 2005;20(4):317-23.
31. Roy CL, Poon EG, Karson AS, Ladak-Merchant Z, Johnson RE, Maviglia SM, Gandhi TK.
Patient safety concerns arising from test results that return after hospital discharge. Ann Intern
Med. 2005;143(2):121-8.
32. Sequist TD, Gandhi TK, Karson AS, Fiskio JM, Bugbee D, Sperling M, Cook EF, Orav EJ,
Fairchild DG, Bates DW. A randomized trial of electronic clinical reminders to improve quality of
care for diabetes and coronary artery disease. J Am Med Inform Assoc. 2005;12(4):431-7.
33. Frankel A, Grillo SP, Baker EG, Huber CN, Abookire S, Grenham M, Console P, O'Quinn M,
Thibault G, Gandhi TK. Patient safety leadership WalkRounds at Partners Healthcare: learning
from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-37.
34. Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E, Poon EG, Leape LL, Bates DW.
Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med.
2005;20(9):837-41.
35. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relationship between patient satisfaction
and physician complaint and malpractice experiences. Am J Med. 2005;118(10):1126-33.
36. Gandhi TK, Graydon-Baker E, Huber CN, Whittemore AD, Gustafson M. Closing the loop:
follow-up and feedback in a patient safety program. Jt Comm J Qual Patient Saf.
2005;31(11):614-21.
37. Gandhi TK, Bartel SB, Shulman LN, Verrier D, Burdick E, Cleary A, Rothschild JM, Leape LL,
Bates DW. Medication safety in the ambulatory chemotherapy setting. Cancer.
2005;104(11):2477-83.
38. Seger AC, Gandhi TK, Hope C, Overhage JM, Murray MD, Weber D, Fiskio J, Teal E, Bates
DW. Development of a computerized adverse drug event (ADE) monitor in the outpatient setting
using electronic medical record data. Advances in Patient Safety: From Research to
Implementation. Agency for Healthcare Research and Quality. 2006;2:173-83.
39. Nicholson D, Hersh W, Gandhi TK, Weingart SN, Bates DW. Medical errors: not just a few 'bad
apples'. J Clin Out Mgmt. 2006;(13):114-5.
40. Goldszer RC, Rittenberg E, Gandhi TK, Katzman L, Sadoughi S, Berone K, Winshall JS.
Primary care morbidity and mortality conference: new use of an old process. JCOM.
2006;13(5):288-91.
28
41. Hurley AC, Lancaster D, Hayes J, Wilson-Chase C, Bane A, Griffin M, Warden V, Duffy ME,
Poon EG, Gandhi TK. The medication administration system--nurses assessment of satisfaction
(MAS-NAS) scale. J Nurs Scholarsh. 2006;38(3):298-300.
42. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks
MM. A prospective study of patient safety in the operating room. Surgery. 2006;139(2):159-73.
43. Cina JL, Gandhi TK, Churchill W, Fanikos J, McCrea M, Mitton P, Rothschild JM, Featherstone
E, Keohane C, Bates DW, Poon EG. How many hospital pharmacy medication dispensing errors
go undetected? Jt Comm J Qual Patient Saf. 2006;32(2):73-80.
44. Shah NR, Seger AC, Seger DL, Fiskio JM, Kuperman GJ, Blumenfeld B, Recklet EG, Bates DW,
Gandhi TK. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am
Med Inform Assoc. 2006;13(1):5-11.
45. Lasser KE, Seger DL, Yu DT, Karson AS, Fiskio JM, Seger AC, Shah NR, Gandhi TK,
Rothschild JM, Bates DW. Adherence to black box warnings for prescription medications in
outpatients. Arch Intern Med. 2006;166(3):338-44.
46. Studdert DM, Mello MM, Gawande AA, Gandhi TK, Kachalia A, Yoon C, Puopolo AL, Brennan
TA. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med.
2006;354(19):2024-33.
47. Poon EG, Cina JL, Churchill W, Patel N, Featherstone E, Rothschild JM, Keohane CA,
Whittemore AD, Bates DW, Gandhi TK. Medication dispensing errors and potential adverse drug
events before and after implementing bar code technology in the pharmacy. Ann Intern Med.
2006;145(6):426-34.
48. Grant RW, Wald JS, Poon EG, Schnipper JL, Gandhi TK, Volk LA, Middleton B. Design and
implementation of a web-based patient portal linked to an ambulatory care electronic health
record: Patient Gateway for diabetes collaborative care. Diabetes Technol Ther. 2006;8(5):576-86.
49. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Missed
and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern
Med. 2006;145(7):488-96.
50. Poon EG, Blumenfeld B, Hamann C, Turchin A, Graydon-Baker E, McCarthy PC, Poikonen J,
Mar P, Schnipper JL, Hallisey RK, Smith S, McCormack C, Paterno M, Coley CM, Karson A,
Chueh HC, Van Putten C, Millar SG, Clapp M, Bhan I, Meyer GS, Gandhi TK, Broverman CA.
Design and implementation of an application and associated services to support interdisciplinary
medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform
Assoc. 2006;13(6):581-92.
51. Matheny ME, Gandhi TK, Orav EJ, Ladak-Merchant Z, Bates DW, Kuperman GJ, Poon EG.
Impact of an automated test results management system on patients' satisfaction about test result
communication. Arch Int Med. 2007;167(20):2233-2239.
52. Hurley AC, Bane A, Fotakis S, Duffy ME, Sevigny A, Poon EG, Gandhi TK. Nurses' satisfaction
with medication administration point-of-care technology. J Nurs Adm. 2007;37(7/8):343-349.
53. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert
DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice
claims from four liability insurers. Ann Emerg Med. 2007;49(2):196-205.
54. Maviglia S, Yoo J, Franz C, Featherstone E, Churchill W, Bates DW, Gandhi TK, Poon EG. Cost
benefit analysis of a hospital pharmacy barcode solution. Arch Int Med. 2007;167:788-794.
55. Keohane CA, Bane AD, Featherstone E, Hayes J, Woolf S, Hurley A, Bates DW, Gandhi TK,
Poon E. Quantifying nursing workflow in medication administration. J Nurs Adm. 2008;38(1):19-
26.
56. Matheny ME, Sequist TD, Seger AC, Fiskio JM, Sperling M, Bugbee D, Bates DW, Gandhi TK.
A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. J
29
Am Med Inform Assoc 2008; 15:424-429.
57. Schnipper JL, Gandhi TK, Wald JS, Grant RW, Poon EG, Volk LA, Businger A, Siteman E,
Buckel L, Middleton B. Design and implementation of a web-based patient portal linked to an
electronic health record designed to improve medication safety: the Patient Gateway medications
module. Inform Prim Care 2008 (16): 147-155.
58. Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Wahlstrom SA, Diedrichsen EK, Carty MG,
Karson AS, Bhan I, Coley CM, Liang CL, Turchin A, McCarthy P, Schnipper JL. Classifying and
predicting errors of inpatient medication reconciliation. J Gen Intern Med 2008; 23(9):1414-22.
59. Turchin A, Hamann C, Schnipper JL, Graydon-Baker E, Millar SG, McCarthy PC, Coley CM,
Gandhi TK, Broverman CA . Evaluation of an inpatient computerized medication reconciliation
system. J Am Med Inform Assoc 2008; 1:449-452.
60. Gandhi TK, Keating NL, Ditmore M, Kiernan D, Johnson R, Burdick E, Hamann C. Improving
referral communication using a referral tool within an electronic medical record. AHRQ Advances
in Patient Safety: New Directions and Alternative Approaches 2008 (3): 63-74.
61. Grant RW, Wald JS, Schnipper JL, Gandhi TK, Poon EG, Orav EJ, Williams DH, Volk LA,
Middleton B. Practice-linked online personal health records for Type 2 diabetes: a randomized
controlled trial. Arch Int Med 2008; 168(16):1776-1782.
62. Graham RE, Gandhi TK, Borus J, Seger AC, Burdick E, Bates DW, Phillips RS, Weingart SN.
Risk of concurrent use of prescription drugs with herbal and dietary supplements in ambulatory
care. AHRQ Advances in Patient Safety: New Directions and Alternative Approaches 2008 (4):
223-235.
63. Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. Impact of non-interruptive medication
laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc 2009; 16: 66-71.
64. Paterno MD, Maviglia SM, Gorman P, Seger DL, Yoshida E, Seger AC, Bates DW, Gandhi TK.
Tiering drug-drug interaction alerts by severity increases acceptance rates. J Am Med Inform
Assoc 2009; 16: 40-46.
65. Roy CL, Kachalia A, Woolf S, Burdick E, Karson A, Gandhi TK. Hospital readmissions:
physician awareness and communication practices. J Gen Intern Med 24(3):374-80.
66. Poon EG, Keohane CA, Bane A, Featherstone E, Hays BS, Dervan A, Woolf S, Hayes J,
Newmark LP, Gandhi TK. Impact of barcode medication administration technology on how
nurses spend their time providing patient care. JONA 2008; 38(12).
67. Schnipper JL, Hamann C, Ndumele CD, Liang CL, Carty MG, Karson AS, Bhan I, Coley CM,
Poon E, Turchin A, Labonville SA, Diedrichsen EK, Lipsitz S, Broverman CA, McCarthy P,
Gandhi TK. Effect of an electronic medication reconciliation application and process redesign on
potential adverse drug events: a cluster-randomized trial. Arch Intern Med 2009; 169(8):771-780.
68. El-Kareh R, Gandhi TK, Poon EG, Newmark LP, Ungar J, Lipsitz S, Sequist TD. Trends in
primary care clinician perceptions of a new electronic health record. J Gen Intern Med 2009;
24(4): 464-8.
69. Weingart SN, Saadeh MG, Simchowitz B, Gandhi TK, Nekhlyudov L, Studdert DM, Puopolo
AL, Shulman LN. Process of care failures in breast cancer diagnosis. J Gen Intern Med 2009;
24(6):702-709.
70. Karnon J, McIntosh A, Dean J, Bath P, Hutchinson A, Oakley J, Thomas N, Pratt P, Freeman-
Parry L, Karsh B-T, Gandhi T, Tappenden P. Modelling the expected net benefits of interventions
to reduce the burden of medication errors. J Heath Serv Res and Policy 2008; 13(2): 85-91.
71. Caputo KM, Cina J, Patel N, Churchill W, Gandhi TK, Poon EP. Overcoming barriers to the
implementation of a pharmacy bar code scanning system for medication dispensing: a case study.
J Am Med Inform Assoc 2009; 16:645-650.
72. Schnipper JL, Roumie CL, Cawthon C, Businger A, Dalal AK, Mugalla I, Eden S, Jacobsen TQ,
30
Rask KJ, Vaccarino V, Gandhi TK, Bates DW, Johnson DC, Labonville S, Gregory D, Kripalani
S. Rationale and design of the pharmacist intervention for low literacy in cardiovascular disease
(PILL-CVD) study. Circ Cardiovasc Qual Outcomes 2010; 3: 212-219.
73. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, Moniz T, Rothschild
JM, Kachalia AB, Hayes J, Churchill WW, Lipsitz S, Whittemore AD, Bates DW, Gandhi TK.
Effect of bar-code technology on the safety of medication administration. N Eng J Med 2010; 362:
1698-707.
74. Gandhi TK, Seger AC, Overhage JM, Murray MD, Hope C, Fiskio J, Teal E, Bates DW.
Outpatient adverse drug events identified by screening electronic health records. J Pat Safety
2010; 6(2): 91-96.
75. Wald JS, Businger A, Gandhi TK, Grant RW, Poon EG, Schnipper JL, Volk LA, Middleton B.
Implementing Practice-linked Previsit Electronic Journals in Primary Care: Patient and Physician
Use and Satisfaction. J Am Med Inform Assoc 2010; 17:502-506.
76. Dalal AK, Poon EG, Karson AS, Gandhi TK, Roy CL. Lessons learned from implementation of a
computerized application for pending tests at hospital discharge. J Hosp Med Nov 15 2010 [Epub
ahead of print] PMID: 21080434.
77. El-Kareh, RE, Gandhi TK, Poon EG, Newmark LP, Ungar J, Orav EJ, Sequist TD. Actionable
reminders did not improve performance over passive reminders for overdue tests in the primary
care setting. J Am Med Inform Assoc 2011; 18: 160-163.
78. Anthony, SG, Prevedello, LM, Damiano MM, Gandhi TK, Doubilet PM, Seltzer SE, Khorasani
R. Impact of a 4 year Quality Improvement Initiative to Improve Communication of Critical
Imaging Test Results. Radiology 2011; 259: 802-807.
79. Turchin A, James OD, Godlewski ED, Shubina M, Coley CM, Gandhi TK, Broverman C.
Effectiveness of interruptive alerts in increasing application functionality utilization: a controlled
trial. J Biomed Inform 2011; 44: 463-468.
80. Nanji KC, Rothschild JM, Salzberg C, Keohane CA, Zigmont K, Devita J, Gandhi TK, Dalal AK,
Bates DW, Poon EG. Errors associated with outpatient computerized prescribing systems. J Am
Med Inform Assoc (2011); 18: 767-773. doi:10.1136/amiajnl-2011-000205.
81. Wright A, Poon EG, Wald J, Feblowitz JC, Schnipper JL, Grant RW, Gandhi TK, Volk LA,
Bloom A, Williams DH, Gardner K, Epstein M, Nelson L, Businger A, Li Q, Bates DW,
Middleton B. Randomized controlled trial of health maintenance reminders provided directly to
patients through an electronic PHR. J Gen Int Med 2012; 27(1): 85-92.
82. Schnipper JL, Gandhi TK, Wald JS, Grant RW, Poon EG, Volk LA, Businger A, Williams DH,
Siteman E, Bucket L, Middleton B. Effects of an online personal health record on medication
accuracy and safety: a cluster-randomized trial. J Am Med Inform Assoc 2012, doi:
10.1136/amiajnl-2011-000723; J Am Med Inform Assoc 2012;19:728-734.
83. Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. Cognitive errors and logistical
breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: A
process analysis of closed malpractice claims. J Gen Int Med 2012, doi: 10.1007/s11606-012-
2107-4.
84. Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, Shintani A, Sponsler KC,
Harris LJ, Theobald C, Huang RL, Scheurer D, Hunt S, Jacobson TA, Rask KJ, Vaccarino V,
Gandhi TK, Bates DW, Williams MV, Schnipper JL, for the PILL-CVD study group. Effect of a
pharmacist intervention on clinically important medication errors after hospital discharge: a
randomized controlled trial. Ann Intern Med 2012;157:1-10.
85. Kale A, Keohane C, Maviglia S, Gandhi TK, Poon EG. Rate of conversion of potential ADEs to
ADEs. BMJ Qual Saf doi: 10.1136/bmjqs-2012-000946.
86. Pernar LIM; Shaw TJ; Pozner CN; Vogelgesang KR; Lacroix SE; Gandhi TK; Peyre SE. Using
31
an Objective Structured Clinical Examination to Test Adherence to Joint Commission National
Patient Safety Goal-Associated Behaviors. Jt Comm J 2012; 38(9): 414-418.
87. Shaw, TJ, Perner LIM, Peyre SE, Helfrick JF, Vogelgesang K, Graydon-Baker E, Chretien Y,
Brown EJ, Nicholson J, Heit JJ, Co JP, and Gandhi TK. Impact of online education on intern
behaviour around Joint Commission National Patient Safety Goals: A randomised trial. BMJ Qual
Saf 2012; 21:819-825.
88. Roy CL, Rothschild JM, Dighe AS, Schiff GD, Graydon-Baker E, Lenoci-Edwards J, Dwyer C,
Khorasani R, Gandhi TK. An Initiative to Improve the Management of Clinically Significant Test
Results in a Large Health Care Network. Jt Comm J 2013; 39(11): 517-527.
89. Dalal AK, Roy CL, Poon EG, Williams DH, Nolido N, Yoon C, Budris J, Gandhi TK, Bates DW,
Schnipper JL. Impact of an automated email notification system for results of tests pending at
discharge: a cluster-randomized control trial. . J Am Med Inform Assoc 2013, doi:
10.1136/amiajnl-2013-002030; J Am Med Inform Assoc 2013; 0: 1-8.
90. Lacson, R, Prevedello LM, Andriole KP, Gill R, Lenoci-Edwards J, Roy C, Gandhi TK,
Khorasani R. Factors Associated with Radiologists' Adherence to Fleischner Society Guidelines
for Management of Pulmonary Nodules. J Am Coll Rad [in press].
91. Leung AA, Denham CR, Gandhi TK, Bane A, Churchill WW, Bates DW, Poon EG. A Safe
Practice Standard for Barcode Technology. J Patient Saf. 2014 Mar 10. [Epub ahead of print].
92. Abookire S, Gandhi TK, Kachalia A, Sands K, Mort E, Bommarito G, Gagne J, Sato L,Weingart
S. (2014). Creating a Fellowship Curriculum in Patient Safety and Quality. American Journal of
Medical Quality, [online] p.1062860614549012. Available at:
http://ajm.sagepub.com/content/early/2014/08/31/1062860614549012 [Accessed 3 Sep. 2014];
also American Journal of Medical Quality 2016, Vol. 31(1) 27-30. 2016, January
93. Gandhi TK, Abookire S, Kachalia A, Sands K, Mort E, Bommarito G, Gagne J, Sato L,
Weingart, S. (2014). Design and Implementation of the Harvard Fellowship in Patient Safety and
Quality. American Journal of Medical Quality, [online] p.1062860614549183. Available at:
http://ajm.sagepub.com/content/early/2014/08/31/1062860614549183 [Accessed 3 Sep. 2014];
also American Journal of Medical Quality 2016, Vol. 31(1) 22-26. 2016, January
94. Edgman-Levitan S, Gandhi T. Empowering Patients as Partners in Health Care. Health
Affairs Blog. 24 July 2014. Available at: http://healthaffairs.org/blog/2014/07/24/empowering-
patients-as-partners-in-health-care/
95. Lacson R, Prevedello L, Andriole K, O’Connor S, Roy C, Gandhi TK, Dalal A, Sato L,
Khorasani, R. Four-Year Impact of an Alert Notification System on Closed-Loop Communication
of Critical Test Results; American Journal Roentg 2014 203:5, 933-938. 96. Gandhi, T, Wachter R, Meyer, G, McTiernan,P. Patient Safety is Not Elective Debate at the
NPSF Patient Safety Congress, BMJ Qual Saf 10.1136/bmjqs-2014-003429.
97. Overhage JM, Gandhi TK, Hope, C, Seger AC, Murray MD,; Orav EJ, Bates DW. Journal of
Patient Safety, JPS-11-219R2 Ambulatory Computerized Prescribing and Preventable Adverse
Drug Events, 2015, May.
98. Thomas H. Payne, Sarah Corley, Theresa A. Cullen, Tejal K. Gandhi, Linda Harrington, Gilad J.
Kuperman, John E. Mattison, David P. McCallie, Clement J. McDonald, Paul C. Tang, William
M. Tierney, Charlotte Weaver, Charlene R. Weir, Michael H. Zaroukian. Report of the AMIA
EHR 2020 Task Force on the Status and Future Direction of EHRs; Journal of the American
Medical Informatics Association, 2015, May.
99. Leung A, Denham C, Gandhi TK, Bane A, Churchill W, Bates, DW. Poon, EG. A Safe Practice
Standard for Barcode Technology; J Pt Safety 2015, June.
100.Wachter R, Gary S. Kaplan, Tejal Gandhi, Lucian Leape. You Can’t Understand Something You
Hide: Transparency As A Path To Improve Patient Safety; Health Affairs Blog, 2015, June.
32
101.Corrigan JM, Wakeam E, Gandhi TK, Leape LL. Improved Patient Safety with Value-Based
Payment Models. HFM Magazine. Healthcare Financial Management Association. 2015, August.
Available at: https://www.hfma.org/Content.aspx?id=32499
Non-peer reviewed scientific or medical publications/materials in print or other media
1. Gandhi TK, Clark PC. Glossary. In: Pathophysiology of Heart Disease. Lilly L, editor.
Philadelphia, PA: Lea and Febiger; 1993. p. 307-13.
2. Gandhi TK, Seger DL, Bates DW. Identifying drug safety issues: from research to practice. Int J
Qual Health Care. 1999; 12(1):69-76.
3. Kuperman GJ, Teich JM, Gandhi TK, Bates DW. Patient safety and computerized medication
ordering at Brigham and Women's Hospital. Jt Comm J Qual Impr. 2001;27(10):509-21.
4. Gandhi TK, Bates DW. Using JCAHO's new patient safety standards to improve medication
safety. JCAHO Pt Safety Newsletter. 2001;1(3):6-7.
5. Gandhi TK, Bates DW. Computer adverse drug event (ADE) detection and alerts. Making health
care safer: A critical analysis of patient safety practices. Shojania KG, Duncan BW, McDonald
KM, Wachter RM, editors. Evidence Report/Technology Assessment No. 43, AHRQ Publication
No. 01-E058; July 2001. Full report available at: http://www.ahrq.gov. 2001.
6. Gandhi TK, Shojania KG, Bates DW. Protocols for high-risk drugs: Reducing adverse drug
events related to anticoagulants. Making health care safer: A critical analysis of patient safety
practices. Shojania KG, Duncan BW, McDonald KM, Wachter RM, editors. Evidence
Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058; July 2001. Full report
available at: http://www.ahrq.gov. 2001.
7. Wang SJ, Blumenfeld BH, Roche SE, Greim JA, Burk KE, Gandhi TK, Bates DW, Kuperman
GJ. End of visit: design considerations for an ambulatory order entry module. Proc AMIA Symp.
2002:864-8.
8. Kuperman GJ, Gandhi TK, Bates DW. Effective drug-allergy checking: Methodological and
operational issues. J Biomed Inform. 2003;36:70-9.
9. Middleton B, Gandhi TK, Bates DW. Patient safety: The role of information technology. In:
Effective management of healthcare information: Leadership roles, challenges, and solutions.
Chicago, IL: HIMSS (Healthcare Information Management and Systems Society)
Publications;2003.
10. Bates DW, Kuperman GJ, Wang S, Gandhi TK, Kittler A, Volk L, Spurr C, Khorasani R,
Tanasijevic M, Middleton B. Ten commandments for effective decision support: Making the
practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003; 10:523-30.
11. Morimoto T, Gandhi TK, Seger AC, Hsieh TC, Bates DW. Adverse drug events and medication
errors: Detection and classification methods. Qual Saf Health Care. 2004; 13:306-14.
12. Kaushal R, Gandhi TK, Bates DW. Epidemiology of medication errors and prevention strategies.
In: Patient Safety in the Process of Medications. Cassiani SH, Ueta J, editors. Editora Artes
Medicas Ltda;2004. p. 21-31.
13. Gandhi TK, Kaushal R, Bates DW. Introduction to patient safety. In: Patient safety in the process
of medications. Cassiani SH, Ueta J, editors. Editora Artes Medicas Ltda;2004. p. 1-10.
14. Gandhi TK. Fumbled hand-offs: One dropped ball after another. Ann Intern Med. 2005;142:352-
8.
15. Greenberg CC, Roth EM, Sheridan TB, Gandhi TK, Gustafson ML, Zinner MJ, Dierks MM.
Making the operating room of the future safer. Am Surg. 2006;72(11):1102-8.
16. Roy CL, Poon EG, Gandhi TK. Managing test results during the transition from hospital to home:
The experience of two academic medical centers. In: Getting results: Reliably communicating and
33
acting on critical test results. Schiff GD, editor. Oakbrook Terrace, IL: Joint Commission
Resources; 2006. p. 19-29.
17. Kuperman GJ, Bobb A, Payne TH, Avery AJ, Gandhi TK, Burns G, Classen DC, Bates DW.
Medication-related clinical decision support in computerized provider order entry systems: A
review. J Am Med Inform Assoc. 2007;14:29-40.
18. Fiumara K, Moniz T, Churchill WW, Bane A, Luppi CJ, Bates DW, Gandhi TK. Case study on
the use of healthcare technology to improve medication safety. Medication Use: A systems
approach to reducing errors, second edition. Joint Commission Resources. 2008.
19. Graydon Baker E, Gandhi T, Conde P, Gustafson M. “Closing the loop to sustain improvements
in patient safety” in Implementing and Sustaining Improvement in Health Care. Joint Commission
Resources 2009: 24-29.
20. Wald J, Grant R, Schnipper J, Gandhi T, Poon E, Businger A, Orav E, Williams D, Volk L,
Middleton B. Survey analysis of patient experience using a practice-linked PHR for Type 2
diabetes mellitus. Proceedings AMIA Annual Meeting, San Francisco, CA, 2009.
21. Gandhi TK, Bates DW. “An Interview with Tejal Gandhi” Jt Comm J Qual Saf 2009 (35); 587-
589.
22. Gandhi TK, Lee TH. Patient safety beyond the hospital. New Eng J Med 2010; 363(11): 1001-
1003.
23. Siegel LC, Gandhi TK. “Outpatient endoscopy: Closing the loop on colonoscopy orders” in The
Value of Close Calls in Improving Patient Safety: Learning How to Avoid and Mitigate Patient
Harm. Joint Commission Resources 2011; 69-75.
24. Gandhi TK, Zuccotti G, Lee TH. Incomplete Care — On the Trail of Flaws in the System. New
Eng J Med 2011; 365(6): 486-488.
25. Gandhi TK, Gardner R. Book chapter. Patient Safety in Office Gynecology in Emans, Laufer,
Goldstein’s Pediatric and Adolescent Gynecology 2012. http://www.amazon.com/Laufer-
Goldsteins-Pediatric-Adolescent-Gynecology/dp/1608316483
26. Bates DW, Gandhi TK. Patient Safety Research at Brigham and Women’s Hospital. In: Tishler
PV, Wenc C, Loscalzo J. eds. The Teaching Hospital: Brigham and Women’s Hospital and the
Evolution of Academic Medicine. Peter Tishler, Cristine Wenc and Joseph Loscalo. 1st ed.
McGraw-Hill Education, 2014. 178-180.
27. Gandhi TK. Guest Editorial: Collaboration at the Heart of Patient Safety. J Rad Nurs. 2014 Sept;
33(3): 97.
28. Bates, David W., and Tejal K. Gandhi. ‘Patient Safety and Research at Brigham and Women’s
Hospital’. The Teaching Hospital: Brigham and Women’s Hospital and the Evolution of Academic
Medicine. Peter Tishler, Cristine Wenc and Joseph Loscalo. 1st ed. McGraw-Hill Education, 2014.
178-180.
29. Hammergren JH, Gandhi TK. Commentary: The key to patient safety? Innovation. 3 Dec 2014.
Government Health IT. http://www.govhealthit.com/news/commentary-key-patient-safety-
innovation
30. Gandhi TK. HTM Plays ‘Critical Role’ in Patient Safety, NPSF Leader Says. Biomed Instrum
Technol. 2015 Jul-Aug; 49(4)269-72. Doi 10.2345/0899-8205-49.4.269.
34
Professional educational materials or reports, in print or other media
1. Gandhi TK. Urine a tough position. AHRQ WebM&M. Available at:
http://www.webmandm.com/cases.aspx?ic=35. 2003.
2. Siegel LC, Gandhi TK. Hospital admission due to high-dose methotrexate drug interaction.
AHRQ WebM&M [serial online]. January 2009. Available at:
http://webmm.ahrq.gov/case.aspx?caseID=193. Accessed January 29, 2009.
3. Gandhi, TK. Ambulatory Patient Safety: Risks and Opportunities. Quantia MD [online course].
https://secure.quantiamd.com/community/dnh. Accessed November 11, 2010.
4. Gandhi TK. Missed and delayed diagnosis in the outpatient setting. Quantia MD [online course].
Website pending. 2010
5. In conversation with Tejal K. Gandhi, MD, MPH [interview]. AHRQ WebM&M [serial online].
April 2014. Available at: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=155.
6. National Patient Safety Foundation. Safety is Personal: Partnering with Patients and Families for
the Safest Care. [roundtable educational report] 2014. Available at:
https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/LLI/Safety_Is_Personal.pdf
7. National Patient Safety Foundation. Shining a Light: Safer Health Care Through
Transparency.[roundtable educational report] 2015. Available at:
https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/LLI/Shining-a-
Light_Transparency.pdf
8. National Patient Safety Foundation. RCA2: Improving Root Cause Analysis and Action [roundtable
educational report]. 2015. Available at: http://www.npsf.org/?page=RCA2
9. National Patient Safety Foundation (2015). Free From Harm: Accelerating Patient Safety
Improvement 15 Years after To Err is Human. [expert panel educational report] 2015. Available
at: http://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/Free_from_Harm.pdf
Clinical Guidelines and Reports
1. Sexton DJ, Corey GR, Carpenter C, Long LK, Gandhi T, Breitschwerdt E, Hegarty B, Chen S,
Feng H, Yu X, Olano J, Walker DH, Dumler SJ. Dual Infection with Ehrlichia chaffeensis and a
spotted fever group rickettsia: a case report. Emerging Infectious Diseases. 1998; 4:311-16.
Abstracts, Poster Presentations and Exhibits Presented at Professional Meetings
1. Middleton B, Gandhi TK, Bates DW. Recommendations for Outpatient Technology to Improve
Patient Safety. Proceedings AHRQ Ambulatory Patient Safety Meeting, Washington, DC. 2001.
2. Wang SJ, Blumenfeld BH, Roche SE, Greim JA, Burk KE, Gandhi TK, Bates DW, Kuperman
GJ. End of visit: design considerations for an ambulatory order entry module. In: Proc AMIA
Symp; San Antonio, TX;2002. p. 864-8.
3. Kuperman GJ, Marston E, Paterno M, Rogala J, Plaks N, Hanson C, Blumenfeld B, Middleton B,
Spurr CD, Kaushal R, Gandhi TK, Bates DW. Creating an enterprise-wide allergy repository at
Partners HealthCare System. In: AMIA Annu Symp Proc; Washington, DC; 2003. p.376-80.
4. Dierks MM, Christian CK, Roth EM, Sheridan TB, Dwyer K, Gandhi TK, Gustafson M, Zinner
MJ. Healthcare safety: the impact of disabling ‘safety’ protocols. In: Proc Human Factors and
Ergonomics Society 47th Annual Meeting; Denver, CO; 2003. p 400-4.