curriculum vitae - harvard medical school · 2018-06-25 · 1 curriculum vitae date prepared:...

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

http://cv.hms.harvard.edu/index.php?page=education

http://cv.hms.harvard.edu/index.php?page=postdoc

http://cv.hms.harvard.edu/index.php?page=academic_appt

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


Member

1998-2000 PHO Information Systems Committee Brigham and Women's Hospital

Member

http://cv.hms.harvard.edu/index.php?page=admin

http://cv.hms.harvard.edu/index.php?page=service

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


Chairperson

2000 Medication Use Process Improvement

Committee


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


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


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


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

http://cv.hms.harvard.edu/index.php?page=societies

http://cv.hms.harvard.edu/index.php?page=grant

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


Award

Partners Drug Safety Committee


Award

Partners Medication Use/Barcoding

Team


Award

Partners LMR Reminders Team


Award

Partners LMR Prescribing Decision

Support Team


Award

Partners RL Solutions Team

2005 Donabedian Award American Public Health

Association

Career achievement


Award

Partners Nursing Barcode

Satisfaction Team


Award

Partners Medication Reconciliation

Team


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


Award

Partners Patient Safety Leaders

Committee


Award

Partners End of Life Dashboard

http://cv.hms.harvard.edu/index.php?page=honors

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


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


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


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


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


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


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


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

http://cv.hms.harvard.edu/index.php?page=students

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


2004 Patient Doctor III - Patient Safety course Harvard Medical School


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


2007 HMS Health Policy Class Harvard Medical School


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

http://cv.hms.harvard.edu/index.php?page=residents

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


2007-2009 Rob El-Kareh, MD/ Fellow

Supervised his fellowship research projects and career mentoring as well; resulted in


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


2006-2007 The Patient Safety Imperative CME course:

"Executive Patient Safety WalkRounds"

1 hr contact per yr

Boston, MA


2008-

The Patient Safety Imperative CME course:

“Creating a Patient Safety Program”

1 hr contact per yr

Boston, MA


http://cv.hms.harvard.edu/index.php?page=clinical

http://cv.hms.harvard.edu/index.php?page=trainees

http://cv.hms.harvard.edu/index.php?page=peers

16

2009-2010 Update in Hospital Medicine CME course

“Creating a Patient Safety Program”

1 hr contact/yr

Boston, MA


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


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


2012, 2014 Leadership Strategies for Information Technology in Health

Care Co-director 30 hrs/yr

Boston, MA


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


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


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


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


http://cv.hms.harvard.edu/index.php?page=presentations_local

17

2002 A Systems Approach to Error/Lecturer


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


MGH Anesthesia Grand Rounds


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

http://cv.hms.harvard.edu/index.php?page=presentations

19


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


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


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


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


TMIT High Performer Webinar - Ambulatory Patient Safety Issues – Opportunities for

Improvement


Penn State Grand Rounds, Hershey, PA


AAMI Conference, Herndon, VA


North Shore-LIJ Health System Grand Rounds, Great Neck, NY


National Workshop on Quality for Medical Education, Baltimore, MD


NYU School of Medicine Grand Rounds, New York, NY


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 CHA Patient Safety Summit, Wallingford, CT


Kaiser Permanente 5th Annual Patient Safety University, San Diego, CA

22


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


LifePoint CMO and Physician Leaders Meeting, Boston, MA

2014 “Patient Engagement and Patient Safety”/Invited Lecturer

McKesson Leadership Summit, Washington, DC


Maine Patient Safety Academy, Portland, ME


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


Bipartisan Policy Center Promoting Innovation, Washington, DC


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


Duke 10th Annual Patient Safety Conference, Durham, NC


Cassat 18th Annual Symposium, Malvern PA

23


AAMI annual meeting, Denver CO


Tennessee Hospital Association, Sandestin, FL


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


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


2010 “Ambulatory Patient Safety: Risks and Opportunities”/Invited Lecturer


2010 “Creating a Patient Safety Program”/Invited Lecturer


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


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


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.

http://cv.hms.harvard.edu/index.php?page=licensure

http://cv.hms.harvard.edu/index.php?page=practice

http://cv.hms.harvard.edu/index.php?page=innovations_clin

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.

http://cv.hms.harvard.edu/index.php?page=innovations_tech

http://cv.hms.harvard.edu/index.php?page=material

http://cv.hms.harvard.edu/index.php?page=peer_review

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.

http://healthaffairs.org/blog/2014/07/24/empowering-patients-as-partners-in-health-care/

http://healthaffairs.org/blog/2014/07/24/empowering-patients-as-partners-in-health-care/

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

https://www.hfma.org/Content.aspx?id=32499

http://cv.hms.harvard.edu/index.php?page=no_peerreview

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.

http://www.amazon.com/Laufer-Goldsteins-Pediatric-Adolescent-Gynecology/dp/1608316483

http://www.amazon.com/Laufer-Goldsteins-Pediatric-Adolescent-Gynecology/dp/1608316483

http://www.govhealthit.com/news/commentary-key-patient-safety-innovation

http://www.govhealthit.com/news/commentary-key-patient-safety-innovation

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.

http://cv.hms.harvard.edu/index.php?page=print

https://secure.quantiamd.com/community/dnh

http://webmm.ahrq.gov/perspective.aspx?perspectiveID=155

https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/LLI/Safety_Is_Personal.pdf

https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/LLI/Shining-a-Light_Transparency.pdf

https://c.ymcdn.com/sites/npsf.site-ym.com/resource/resmgr/LLI/Shining-a-Light_Transparency.pdf

http://www.npsf.org/?page=RCA2

http://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/Free_from_Harm.pdf

http://cv.hms.harvard.edu/index.php?page=reports

http://cv.hms.harvard.edu/index.php?page=abstracts

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