P. Mills

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Incorrect surgical procedures within and outside of the operating room.

J. Neily, P. Mills, N. Eldridge, 2009, Archives of surgery.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

P Mills, P. Pronovost, R. Thomson, 2008, Quality & Safety in Health Care.

Using aggregate root cause analysis to improve patient safety.

J. Neily, P. Mills, J. Bagian, 2003, Joint Commission journal on quality and safety.

The Case for Training Veterans Administration Frontline Nurses in Crew Resource Management

J. Neily, P. Mills, A. Fore, 2011, The Journal of nursing administration.

A cognitive aid for cardiac arrest: you can't use it if you don't know about it.

Joseph M. Derosier, J. Neily, P. Mills, 2004, Joint Commission journal on quality and safety.

Association between implementation of a medical team training program and surgical mortality.

J. Neily, P. Mills, J. Bagian, 2010, JAMA.

The effect of simulation-based crew resource management training on measurable teamwork and communication among interprofessional teams caring for postoperative patients.

J. Neily, P. Mills, J. Paige, 2013, Journal of continuing education in nursing.

Teamwork and communication in surgical teams: implications for patient safety.

Julia Neily, J. Neily, P. Mills, 2008, Journal of the American College of Surgeons.

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

James P Bagian, Julia Neily, Peter D Mills, 2011, Archives of surgery.

Using aggregate root cause analysis to reduce falls.

William B Weeks, Julia Neily, Erik Stalhandske, 2005, Joint Commission journal on quality and patient safety.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

P. Mills, S. Marcus, B. Watts, 2019, Joint Commission journal on quality and patient safety.

And Treatment of Outpatients Root Cause Analysis Reports Help Identify Common Factors in Delayed Diagnosis Not for Commercial Use or Unauthorized Distribution

R. Hemphill, J. Neily, P. Mills, 2013 .

Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration.

J. Neily, P. Mills, Diana Luan, 2006, Joint Commission journal on quality and patient safety.

Effective interventions and implementation strategies to reduce adverse drug events in the Veterans Affairs (VA) system

J. Neily, P. Mills, J. Bagian, 2008, Quality & Safety in Health Care.

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.

R. Hemphill, J. Neily, P. Mills, 2014, Joint Commission journal on quality and patient safety.

Recommendations for Fall-Related Injury Prevention

J. Neily, P. Mills, T. Bulat, 2020, Journal of nursing care quality.

Reporting Military Sexual Trauma: A Mixed-Methods Study of Women Veterans' Experiences Who Served From World War II to the War in Afghanistan.

P. Mills, K. Wolff, 2016, Military medicine.

Flash Burns While on Home Oxygen Therapy: Tracking Trends and Identifying Areas for Improvement

R. Hemphill, P. Mills, K. Wolff, 2017, American journal of medical quality : the official journal of the American College of Medical Quality.

The Daily Plan®: Including patients for safety's sake

P. Mills, A. Fore, Beth J. King, 2012, Nursing management.

Developing Unique Engineering Solutions to Improve Patient Safety

P. Mills, B. Shiner, B. Watts, 2012 .

VHA’s National Falls Collaborative and Prevention Programs

J. Neily, P. Mills, J. Bagian, 2008 .

Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration.

R. Hemphill, P. Mills, Hasan Shanawani, 2017, Joint Commission journal on quality and patient safety.

Factors contributing to cancer‐related suicide: A study of root‐cause analysis reports

P. Mills, B. Shiner, B. Watts, 2018, Psycho-oncology.

Wrong-side thoracentesis: lessons learned from root cause analysis.

Julia Neily, Peter D Mills, Robin R Hemphill, 2014, JAMA surgery.

Systematic and organizational issues implicated in post-hospitalization suicides of medically hospitalized patients: A study of root-cause analysis reports.

R. Hemphill, P. Mills, B. Shiner, 2017, General hospital psychiatry.

Suicide attempts and completions in Veterans Affairs nursing home care units and long‐term care facilities: a review of root‐cause analysis reports

R. Hemphill, P. Mills, B. Watts, 2016, International journal of geriatric psychiatry.

Impact of over-the-door alarms: Root cause analysis review of suicide attempts and deaths on veterans health administration mental health units.

P. Mills, W. Gunnar, Christina Soncrant, 2020, General hospital psychiatry.

Suicide attempts and completions in the emergency department in Veterans Affairs Hospitals

P. Mills, J. Bagian, B. Watts, 2011, Emergency Medicine Journal.

Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports

R. Hemphill, P. Mills, B. Shiner, 2017, The Journal of nervous and mental disease.

Review of Reported Adverse Events Occurring Among the Homeless Veteran Population in the Veterans Health Administration

P. Mills, W. Gunnar, Christina Soncrant, 2021, Journal of patient safety.

Nursing Crew Resource Management: A Follow-up Report From the Veterans Health Administration

J. Neily, P. Mills, A. Fore, 2013, The Journal of nursing administration.

Adverse events occurring on mental health units.

R. Hemphill, P. Mills, B. Shiner, 2018, General hospital psychiatry.

Clostridium difficile Infection Among Veterans Health Administration Patients

J. Neily, P. Mills, D. Gerding, 2015, Infection Control & Hospital Epidemiology.

Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration

R. Hemphill, J. Neily, P. Mills, 2018, AORN journal.

Suicide and Suicide Attempts on Veterans Affairs Medical Center Outpatient Clinic Areas, Common Areas, and Hospital Grounds

P. Mills, B. Watts, W. Gunnar, 2020, Journal of patient safety.

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process.

Katherine B Percarpio, J. Neily, P. Mills, 2010, Joint Commission journal on quality and patient safety.

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement

J. Neily, P. Mills, Ruth E Politi, 2022, Journal of patient safety.

Veterans Health Administration Response to the COVID-19 Crisis: Surveillance to Action

P. Mills, Maureen A Charles, Edward E. Yackel, 2022, Journal of patient safety.

Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide.

P. Mills, B. Shiner, Y. Young-Xu, 2017, Psychiatric services.

Examination of the effectiveness of the Mental Health Environment of Care Checklist in reducing suicide on inpatient mental health units.

P. Mills, B. Shiner, Y. Young-Xu, 2012, Archives of general psychiatry.

Test-retest reliability of the VA National Center for Patient Safety culture questionnaire.

P. Mills, B. Shiner, Y. Young-Xu, 2016, Journal of evaluation in clinical practice.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration

P. Mills, W. Gunnar, Christina Soncrant, 2021, Journal of patient safety.

The Daily Plan®: Patients Taking Part in Patient Safety

J. Neily, P. Mills, J. Bagian, 2010 .

Suicide attempts and completions on medical-surgical and intensive care units.

R. Hemphill, P. Mills, B. Watts, 2014, Journal of hospital medicine.

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.

R. Hemphill, P. Mills, B. Watts, 2013, General hospital psychiatry.

Learning from prevented suicide in psychiatric inpatient care: an analysis of data from the National Patient Safety Agency.

P. Mills, L. Bowers, Karen James, 2011, International journal of nursing studies.

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.

P. Mills, J. Bagian, J. Derosier, 2008, Joint Commission journal on quality and patient safety.

Helping Elderly Patients to Avoid Suicide: A Review of Case Reports From a National Veterans Affairs Database

P. Mills, B. Watts, J. Kemp, 2013, The Journal of nervous and mental disease.

The Joint Commission Journal on Quality and Patient Safety A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals National Patient Safety Goals

P. Mills, B. Watts, K. Knox, 2010 .

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

P. Mills, J. Bagian, B. Watts, 2011, The journal of ECT.

Investigating the Source of Hepatitis C Virus Infection Among Individuals Whose Route of Infection is Undefined: A Study of Ten Cases

P. Mills, D. Goldberg, Avril Taylor, 2003, Scandinavian journal of infectious diseases.

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units

P. Mills, W. Gunnar, Christina Soncrant, 2020, BMJ Quality & Safety.

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement

James P Bagian, Scott D McKnight, Peter D Mills, 2011, BMJ quality & safety.

An Analysis of Adverse Events in the Rehabilitation Department: Using the Veterans Affairs Root Cause Analysis System

R. Hemphill, P. Mills, B. Shiner, 2018, Physical therapy.

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

Hardeep Singh, Traber Davis Giardina, Julia Neily, 2013, Health affairs.

Using a virtual breakthrough series collaborative to reduce postoperative respiratory failure in 16 Veterans Health Administration hospitals.

Lisa Zubkoff, Julia Neily, Marlena H. Shin, 2014, Joint Commission journal on quality and patient safety.

Improving the bar-coded medication administration system at the Department of Veterans Affairs.

Julia Neily, Peter D Mills, J. Neily, 2006, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

Association between implementation of a medical team training program and surgical morbidity.

James P Bagian, Julia Neily, Peter D Mills, 2011, Archives of surgery.

Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem

J. Neily, P. Mills, Gary L. Sculli, 2018, Journal of patient safety.

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

James P Bagian, Julia Neily, Peter D Mills, 2009, American journal of surgery.

Root cause analysis of serious adverse events among older patients in the Veterans Health Administration.

Julia Neily, Alexandra Lee, Peter D Mills, 2014, Joint Commission journal on quality and patient safety.

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme

Katherine B Percarpio, J. Neily, P. Mills, 2010, Quality and Safety in Health Care.

Collaboration of Ethics and Patient Safety Programs: Opportunities to Promote Quality Care

J. Neily, P. Mills, W. Weeks, 2008, HEC forum : an interdisciplinary journal on hospitals' ethical and legal issues.

Awareness and use of a cognitive aid for anesthesiology.

William B Weeks, James P Bagian, Julia Neily, 2007, Joint Commission journal on quality and patient safety.

Medical team training: applying crew resource management in the Veterans Health Administration.

James P Bagian, Julia Neily, Peter D Mills, 2007, Joint Commission journal on quality and patient safety.

One-year follow-up after a collaborative breakthrough series on reducing falls and fall-related injuries.

Julia Neily, Kierston Howard, Patricia Quigley, 2005, Joint Commission journal on quality and patient safety.

Reduction in patient enrollment in the Veterans Health Administration after media coverage of adverse medical events.

P. Mills, W. Weeks, 2003, Joint Commission journal on quality and safety.

A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration

P. Mills, B. Watts, A. Tomolo, 2020, Journal of patient safety.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

Lisa Zubkoff, Julia Neily, Peter D Mills, 2016, Joint Commission journal on quality and patient safety.

Power Failures During Surgery: A 2000–2019 Review of Reported Events in the Veterans Health Administration

J. Neily, P. Mills, Lisa M Mazzia, 2020, Journal of patient safety.

Use of the Safety Attitudes Questionnaire as a Measure in Patient Safety Improvement

Katherine B Percarpio, P. Mills, B. Watts, 2010, Journal of patient safety.

elaborationreporting: explanation and Reporting Excellence) guidelines for quality The SQUIRE (Standards for QUality Improvement

P. Pronovost, J. Neily, P. Mills, 2008 .

A checklist to identify inpatient suicide hazards in veterans affairs hospitals.

Joseph M. Derosier, P. Mills, J. Bagian, 2010, Joint Commission journal on quality and patient safety.

Developing and Sustaining Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative

D. Haggstrom, P. Mills, M. Kelley, 2010, Journal of General Internal Medicine.

Characteristics of successful quality improvement teams: lessons from five collaborative projects in the VHA.

William B Weeks, Peter D Mills, P. Mills, 2004, Joint Commission journal on quality and safety.

Using an improvement model to reduce adverse drug events in VA facilities.

P B Batalden, R S Dittus, P. Mills, 2001, The Joint Commission journal on quality improvement.

Root Cause Analyses of Reported Adverse Events Occurring During Gastrointestinal Scope and Tube Placement Procedures in the Veterans Health Association.

R. Hemphill, J. Neily, P. Mills, 2017, Journal of patient safety.

Implementing Evidence-Based Pressure Injury Prevention Interventions: Veterans Health Administration Quality Improvement Collaborative.

J. Neily, P. Mills, Y. Young-Xu, 2020, Journal of nursing care quality.

How to do a Virtual Breakthrough Series Collaborative

Lisa Zubkoff, Julia Neily, Peter D. Mills, 2019, Journal of Medical Systems.

Preventing Falls and Fall-Related Injuries in State Veterans Homes: Virtual Breakthrough Series Collaborative

Lisa Zubkoff, Julia Neily, Peter D. Mills, 2017, Journal of nursing care quality.

Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative

Lisa Zubkoff, Julia Neily, Yinong Young-Xu, 2017, Journal of nursing care quality.

Virtual Breakthrough Series, Part 2: Improving Fall Prevention Practices in the Veterans Health Administration.

Lisa Zubkoff, Julia Neily, Peter D Mills, 2016, Joint Commission journal on quality and patient safety.

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

James P Bagian, Julia Neily, Peter D Mills, 2010, American journal of surgery.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

P. Mills, Christina Soncrant, N. Riblet, 2023, Military Medicine.

Root Cause Analysis of Adverse Events Involving Opioid Overdoses in the Veterans Health Administration.

P. Mills, W. Gunnar, Christina Soncrant, 2021, Joint Commission journal on quality and patient safety.

Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR.

James P Bagian, Julia Neily, Peter D Mills, 2010, AORN journal.

Improving Patient Safety and Optimizing Nursing Teamwork Using Crew Resource Management Techniques

J. Neily, P. Mills, A. Fore, 2012, The Journal of nursing administration.

Assessing Readiness to Change of a High Fall Risk Patient: A Case Report

J. Neily, P. Mills, Alexandra Lee, 2012, Care Management Journals.

The Effect of Facility Complexity on Perceptions of Safety Climate in the Operating Room: Size Matters

James P Bagian, Julia Neily, Peter D Mills, 2010, American journal of medical quality : the official journal of the American College of Medical Quality.

Review of alternatives to root cause analysis: developing a robust system for incident report analysis

Albert W Wu, Gregory Hagley, Peter D Mills, 2019, BMJ open quality.

Adverse Patient Safety Events During the COVID Epidemic.

P. Mills, Edward E. Yackel, Regina Knowles, 2023, Journal of patient safety.

Systemic vulnerabilities to suicide among veterans from the Iraq and Afghanistan Conflicts: review of case reports from a National Veterans Affairs Database.

P. Mills, J. Bagian, Samuel J. Huber, 2011, Suicide & life-threatening behavior.

Identification of Inpatient Falls Using Automated Review of Text-Based Medical Records

Bradley V Watts, Brian Shiner, Julia Neily, 2016, Journal of patient safety.

Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program

P. Mills, J. Bagian, W. Weeks, 2010, Quality and Safety in Health Care.

Improving Perceptions of Teamwork Climate With the Veterans Health Administration Medical Team Training Program

J. Neily, P. Mills, J. Bagian, 2011, American journal of medical quality : the official journal of the American College of Medical Quality.

Changing Perceptions of Safety Climate in the Operating Room With the Veterans Health Administration Medical Team Training Program

J. Neily, P. Mills, J. Bagian, 2011, American journal of medical quality : the official journal of the American College of Medical Quality.

The role of the operating room nurse manager in the successful implementation of preoperative briefings and postoperative debriefings in the VHA Medical Team Training Program.

J. Neily, P. Mills, J. Bagian, 2010, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses.

Development and Implementation of a National Interprofessional Fellowship in Patient Safety

R. Hemphill, P. Mills, B. Watts, 2018 .

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned

R. Hemphill, J. Neily, P. Mills, 2017, Anesthesia and analgesia.

A multihospital safety improvement effort and the dissemination of new knowledge.

William B Weeks, Peter D Mills, P. Mills, 2003, Joint Commission journal on quality and safety.

Wrong Site Spine Surgery in the Veterans Administration

P. Mills, B. Watts, D. Paull, 2019, Clinical spine surgery.

Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room

P. Mills, Y. Young-Xu, D. Paull, 2018, JAMA network open.

Sharing Lessons Learned to Prevent Incorrect Surgery

R. Hemphill, P. Mills, J. Turner, 2012, The American surgeon.

Using root cause analysis to reduce falls with injury in community settings.

P. Mills, Alexandra Lee, Julia Neily, 2012, Joint Commission journal on quality and patient safety.

Effect of Colchicine on Clostridium Difficile Infection Incidence, Recurrence, and Severity

P. Mills, C. Wegner, Y. Young-Xu, 2015 .

Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration.

R. Hemphill, P. Mills, J. Turner, 2015, American journal of surgery.

Wrong-side thoracentesis: lessons learned from root cause analysis.

R. Hemphill, P. Mills, L. Williams, 2014, JAMA Surgery.

Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room

P. Mills, Y. Young-Xu, D. Paull, 2018, JAMA network open.

Virtual Breakthrough Series, Part 1: Preventing Catheter-Associated Urinary Tract Infection and Hospital-Acquired Pressure Ulcers in the Veterans Health Administration.

P. Mills, Y. Young-Xu, S. Krein, 2016, Joint Commission journal on quality and patient safety.

Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

P. Mills, A. Wallace, E. Mariano, 2021, Journal of patient safety.

Review of alternatives to root cause analysis: developing a robust system for incident report analysis

A. Wu, P. Mills, B. Watts, 2019, BMJ open quality.

Suicide and Suicide Attempts on Hospital Grounds and Clinic Areas

R. Hemphill, P. Mills, B. Watts, 2017, Journal of patient safety.