U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (6)
Diagnostic Errors (9)
Identification Errors (9)
Discontinuities, Gaps, and Hand-Off Problems (23)
Fatigue and Sleep Deprivation (4)
Medication Safety (23)
Medical Complications (10)
Nonsurgical Procedural Complications (4)
Surgical Complications (82)
Psychological and Social Complications (14)
Australia and New Zealand (8)
North America (170)
Epidemiology of Errors and Adverse Events (51)
Active Errors (40)
Latent Errors (22)
Approach to Improving Safety
Quality Improvement Strategies (28)
Legal and Policy Approaches (15)
Error Reporting and Analysis (37)
Communication Improvement (57)
Human Factors Engineering (33)
Specialization of Care (8)
Logistical Approaches (13)
Culture of Safety (22)
Technologic Approaches (32)
Education and Training (34)
Allied Health Services (1)
Health Care Providers (132)
Health Care Executives and Administrators (182)
Non-Health Care Professionals (97)
Setting of Care
Residential Facilities (2)
Ambulatory Care (12)
Outpatient Surgery (3)
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Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015 Jun 10; [Epub ahead of print].
Concept analysis: wrong-site surgery.
Watson DS. AORN J. 2015;101:650-656.
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.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
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.
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.
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.
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.
Communication devices in the operating room.
Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.
Error training: missing link in surgical education.
DaRosa DA, Pugh CM. Surgery. 2012;151:139-145.
Interventions for reducing wrong-site surgery and invasive procedures.
Algie CM, Mahar RK, Wasiak J, Batty L, Gruen RL, Mahar PD. Cochrane Database Syst Rev. 2015;3:CD009404.
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.
Surgical checklists: a systematic review of impacts and implementation.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Applying fault tree analysis to the prevention of wrong-site surgery.
Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.
Developing a culture of collaboration in the operating room: more than effective communication.
Wade P. ORNAC J. 2014;32:16-20, 22-23, 32-38.
Clinical handover of the critically ill postoperative patient: an integrative review.
Gardiner TM, Marshall AP, Gillespie BM. Aust Crit Care. 2015 Mar 18; [Epub ahead of print].
Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture.
Sacks GD, Shannon EM, Dawes AJ, et al. BMJ Qual Saf. 2015;24:458-467.
Current issues in patient safety in surgery: a review.
Kim FJ, da Silva RD, Gustafson D, Nogueira L, Harlin T, Paul DL. Patient Saf Surg. 2015;9:26.
Effectiveness of interventions to improve patient handover in surgery: a systematic review.
Pucher PH, Johnston MJ, Aggarwal R, Arora S, Darzi A. Surgery. 2015;158:85-95.
A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
Johnston MJ, Arora S, King D, et al. Surgery. 2015;157:752-763.
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