U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Device-related Complications (6)
Diagnostic Errors (6)
Identification Errors (8)
Discontinuities, Gaps, and Hand-Off Problems (19)
Fatigue and Sleep Deprivation (3)
Medication Safety (20)
Medical Complications (9)
Nonsurgical Procedural Complications (4)
Surgical Complications (72)
Psychological and Social Complications (11)
Australia and New Zealand (7)
North America (146)
Epidemiology of Errors and Adverse Events (31)
Active Errors (33)
Latent Errors (21)
Approach to Improving Safety
Quality Improvement Strategies (28)
Legal and Policy Approaches (14)
Error Reporting and Analysis (28)
Communication Improvement (48)
Human Factors Engineering (28)
Specialization of Care (8)
Logistical Approaches (12)
Culture of Safety (21)
Technologic Approaches (26)
Education and Training (32)
Allied Health Services (1)
Health Care Providers (124)
Health Care Executives and Administrators (154)
Non-Health Care Professionals (91)
Setting of Care
Residential Facilities (1)
Ambulatory Care (11)
Outpatient Surgery (3)
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Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.
Communication devices in the operating room.
Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.
Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review.
Pape H, Pfeifer R. Patient Saf Surg. 2009;3:3.
Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety.
Lyons VE, Popejoy LL. West J Nurs Res. 2014;36:245-261.
Interventions for reducing wrong-site surgery and invasive procedures.
Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Cochrane Database Syst Rev. 2012;9:CD009404.
Improving safety in the operating room: a systematic literature review of retained surgical sponges.
Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.
Surgical checklists: a systematic review of impacts and implementation.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.
Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.
Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.
Dagi TF, Berguer R, Moore S, Reines HD. Curr Probl Surg. 2007;44:352-381.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Error training: missing link in surgical education.
DaRosa DA, Pugh CM. Surgery. 2012;151:139-145.
Missed injuries in trauma patients: a literature review.
Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.
Life after death: the aftermath of perioperative catastrophes.
Gazoni FM, Durieux ME, Wells L. Anesth Analg. 2008;107:591-600.
Reducing the burden of surgical harm: a systematic review of the interventions used to reduce adverse events in surgery.
Howell AM, Panesar SS, Burns EM, Donaldson LJ, Darzi A. Ann Surg. 2014;259:630-641.
Patient monitoring alarms in the ICU and in the operating room.
Schmid F, Goepfert MS, Reuter DA. Crit Care. 2013;17:216.
Wrong site surgery in otolaryngology–head and neck surgery.
Liou TN, Nussenbaum B. Laryngoscope. 2014;124:104-109.
Enhancing communication in surgery through team training interventions: a systematic literature review.
Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.
The recurring problem of retained swabs and instruments.
Mahran MA, Toeima E, Morris EP. Best Pract Res Clin Obstet Gynaecol. 2013;27:489-495.
Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.
Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.
Noise in the operating room—what do we know? A review of the literature.
Hasfeldt D, Laerkner E, Birkelund R. J Perianesth Nurs. 2010;25:380-386.
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