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PATIENT SAFETY PRIMERS
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Safety Target
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Device-related Complications (205)
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Diagnostic Errors (84)
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Identification Errors (68)
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Discontinuities, Gaps, and Hand-Off Problems (194)
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Fatigue and Sleep Deprivation (20)
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Medication Safety (521)
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Medical Complications (236)
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Nonsurgical Procedural Complications (115)
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Error Types
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Epidemiology of Errors and Adverse Events (478)
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Active Errors (374)
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Latent Errors (125)
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Near Miss (42)
Approach to Improving Safety
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Error Reporting and Analysis (473)
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Communication Improvement (462)
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Human Factors Engineering (428)
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Teamwork (192)
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Specialization of Care (118)
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Logistical Approaches (87)
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Culture of Safety (218)
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Technologic Approaches (306)
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Education and Training (372)
Clinical Areas
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Allied Health Services (6)
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Complementary and Alternative Medicine (1)
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Dentistry (5)
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Medicine (1369)
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Nursing (90)
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Pharmacy (155)
Target Audience
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Health Care Providers (1578)
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Health Care Executives and Administrators (1656)
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Non-Health Care Professionals (697)
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Patients (81)
Setting of Care
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Hospitals (1164)
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Psychiatric Facilities (8)
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Residential Facilities (24)
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Ambulatory Care (147)
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Outpatient Surgery (22)
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Patient Transport (20)
1 - 20
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STUDY
Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.
Cassidy CJ, Smith A, Arnot-Smith J. Anaesthesia. 2011;66:879-888.
STUDY
Management of anesthesia equipment failure: a simulation-based resident skill assessment.
Waldrop WB, Murray DJ, Boulet JR, Kras JF. Anesth Analg. 2009;109:426-433.
PRESS RELEASE/ANNOUNCEMENT
Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.
Rockville, MD: US Food and Drug Administration; November 9, 2010.
NEWSPAPER/MAGAZINE ARTICLE
Preventing catheter/tubing misconnections: much needed help is on the way.
ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.
STUDY
Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.
Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.
REVIEW
Inappropriate trust in technology: implications for critical care nurses.
Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.
STUDY
Impact of a comprehensive safety initiative on patient-controlled analgesia errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
COMMENTARY
Non-Luer connectors: are we nearly there yet?
Cook TM. Anaesthesia. 2012;67:784-792.
ORGANIZATIONAL POLICY/GUIDELINES
Radiation risks of diagnostic imaging.
Sentinel Event Alert #47. August 24, 2011.
STUDY
Patient safety incidents associated with equipment in critical care: a review of reports to the UK National Patient Safety Agency.
Thomas AN, Galvin I. Anaesthesia. 2008;63:1193-1197.
NEWSPAPER/MAGAZINE ARTICLE
ALERT: reports of severe harm after intravenous administration of breast milk to infants.
ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.
STUDY
Novel analysis of clinically relevant diagnostic errors in point-of-care devices.
Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.
NEWSPAPER/MAGAZINE ARTICLE
Patient safety records: silent witness.
Gould M. Health Service Journal. September 15, 2008:22-24.
STUDY
Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007.
Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.
ORGANIZATIONAL POLICY/GUIDELINES
Checking anaesthetic equipment 2012: Association of Anaesthetists of Great Britain and Ireland.
Hartle A, Anderson E, Bythell V, et al; Membership of the Working Party. Anaesthesia. 2012;67:660-668.
STUDY
Promoting patient safety through prospective risk identification: example from peri-operative care.
Smith A, Boult M, Woods I, Johnson S. Qual Saf Health Care. 2010;19:69-73.
NEWSPAPER/MAGAZINE ARTICLE
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
NEWSPAPER/MAGAZINE ARTICLE
Pharmaceutical industry and medical device companies: part of the solution?
ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.
COMMENTARY
Understanding the role of non-technical skills in patient safety.
White N. Nurs Stand. 2012;26:43-48.
REVIEW
The effect of bedrails on falls and injury: a systematic review of clinical studies.
Healey F, Oliver D, Milne A, Connelly JB. Age Ageing. 2008;37:368-378.
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