Romano and colleagues found that rural hospitals had lower risk-adjusted rates of potential safety-related events for 14 of the 19 indicators (e.g., decubitus ulcer, infection due to medical care, postoperative respiratory failure), and higher rates for 5 indicators (anesthesia reactions and complications, accidental puncture and laceration, postoperative hip fracture, abdominopelvic wound dehiscence, and birth trauma) (Jolliffe, 2003; Romano et al., 2003). An earlier study of New York state hospitals found that rural hospitals had significantly lower adverse event rates than New York City and urban upstate hospitals after controlling for age and severity of illness (Whitener and McGranahan, 2003). Another study examined rural hospitals by bed size and found that, compared with large rural hospitals (100+ beds), both medium-sized (50–99 beds) and small (<50 beds) rural hospitals had significantly lower rates of postoperative hip fracture, hemorrhage, and hematoma; the medium-sized hospitals had lower rates of postoperative respiratory failure, while the small hospitals had lower rates of iatrogenic pneumothorax infection (Cromartie, 2002). On the other hand, a study of rural health clinics documented a wide range of medication errors, including errors in dosage, errors in agent selection, and failure to recognize potential drug interactions and contraindications (Williamson et al., 1991).

Patient safety practices are processes or structures whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures (Shojania et al., 2002). Since the publication of the IOM reports To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001), key organizations involved in patient safety activities have augmented their programs. For example, the National Quality Forum (NQF) has endorsed standards to improve patient safety, the Agency for Healthcare Research and Quality (AHRQ) has published evidence-based studies on specific actions that can increase patient safety, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has expanded initiatives and resources to enhance patient safety in the organizations it accredits (NQF, 2003; AHRQ, 2004; JCAHO, 2004). In addition, health care purchasers, notably represented by the Leapfrog Group, have developed several targeted standards for delivering care to increase safety.

Nonetheless, there is a general absence of studies examining patient safety issues in rural provider settings. Of the few research studies that do exist (Coburn et al., forthcoming; Romano et al., 2003), there has been no evaluation of how the characteristics of rural practice, such as smaller-sized facilities and low volume, may impact patient safety. In addition, rural pro-



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