U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Safety and Medical Education
Device-related Complications (147)
Diagnostic Errors (119)
Identification Errors (69)
Discontinuities, Gaps, and Hand-Off Problems (463)
Fatigue and Sleep Deprivation (114)
Medication Safety (895)
Medical Complications (490)
Nonsurgical Procedural Complications (50)
Surgical Complications (248)
Transfusion Complications (19)
Psychological and Social Complications (161)
Australia and New Zealand (87)
Central and South America (2)
North America (3002)
Clinical Guideline (3)
Journal Article (2523)
Newspaper/Magazine Article (499)
Press Release/Announcement (11)
Special or Theme Issue (43)
Web Resource (81)
Epidemiology of Errors and Adverse Events (1002)
Active Errors (566)
Latent Errors (439)
Near Miss (46)
Approach to Improving Safety
Quality Improvement Strategies (863)
Legal and Policy Approaches (382)
Error Reporting and Analysis (1053)
Communication Improvement (774)
Human Factors Engineering (373)
Specialization of Care (280)
Logistical Approaches (288)
Culture of Safety (504)
Technologic Approaches (587)
Education and Training (635)
Allied Health Services (4)
Health Care Providers (2043)
Health Care Executives and Administrators (2948)
Non-Health Care Professionals (1473)
Setting of Care
General Hospitals (518)
Children’s Hospitals (83)
Specialty Hospitals (31)
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Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.
Kennerly DA, Saldaña M, Kudyakov R, da Graca B, Nicewander D, Compton J. J Patient Saf. 2013;9:87-95.
The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?
Hofmann PB. Healthc Exec. 2012 May-Jun;27:64,66-67.
The Safe Tables Collaborative: a statewide experience.
Wagner CA, Cecchettini D, Fletcher J. Jt Comm J Qual Patient Saf. 2011;37:206-210.
Patient Safety as an Exercise in Behavioral Change.
Leape LL. Social and Behavioral Sciences in Action. Washington, DC: National Research Council of the National Academies. September 24, 2012.
Could it happen here? Learning from other organizations' safety errors.
Conway J. Healthc Exec. November/December 2008;23:64-67.
The competitive imperative of learning.
Edmondson AC. Harv Bus Rev. 2008;86:60-67, 160.
Patient safety climate in hospitals: act locally on variation across units.
Campbell EG, Singer S, Kitch BT, Iezzoni LI, Meyer GS. Jt Comm J Qual Patient Saf. 2010;36:319-326.
A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.
Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.
The 2012 Fifth International High Reliability Conference Proceedings.
Oakbrook Terrace, IL: Joint Commission; May 21–23, 2012.
Minnesota Hospital Association Statewide Project: SAFE from FALLS.
Apold J, Quigley PA. J Nurs Care Qual. 2012;27:299-306.
Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.
Luther K, Resar RK. Healthc Exec. Jan/Feb 2013;28:84-87.
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
Transparency and public reporting are essential for a safe health care system.
Leape LL. Perspect Health Reform. New York, NY: The Commonwealth Fund; March 17, 2010.
Tennessee Center for Patient Safety.
"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.
Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.
Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.
Hansen LO, Greenwald JL, Budnitz T, et al. J Hosp Med. 2013;8;421-427.
Learning accountability for patient outcomes.
Pronovost PJ. JAMA. 2010;304:204-205.
Speaking Up Constructively: Managerial Practices that Elicit Solutions from Front-Line Employees.
Adler-Milstein JR, Singer SJ, Toffel MW. Cambridge, MA: Harvard Business School; August 25, 2010. HBS Working Paper No. 11-005.
Design and implementation of an automated email notification system for results of tests pending at discharge.
Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.
CUSP Implementation Workshop.
Armstrong Institute for Patient Safety and Quality. July 21, 2015; Constellation Energy Building Conference Center, Baltimore, MD.
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