U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Device-related Complications (21)
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Identification Errors (63)
Discontinuities, Gaps, and Hand-Off Problems (44)
Fatigue and Sleep Deprivation (25)
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Nonsurgical Procedural Complications (6)
Surgical Complications (572)
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Approach to Improving Safety
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Setting of Care
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'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
Surgical checklists: a systematic review of impacts and implementation.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
When surgery goes wrong: weighing up the risks.
Feinmann J. The Independent. November 14, 2006.
Bringing surgeons down to earth.
Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.
Errors with concentrated epinephrine in otolaryngology.
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
When the bone flap hits the floor.
Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.
Tomorrow's operating room to harness Net, RFID.
Olsen S. CNET News.com; October 19, 2005.
Collegiality vs. Competence
Sagin T. AHRQ WebM&M [serial online]. March 2006.
Surgery fires spur need for new guidelines.
Collins D. Associated Press [MSNBC]. July 26, 2007.
Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.
Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.
Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.
ASA Task Force on Intraoperative Awareness and Brain Function Monitoring. Park Ridge, IL: American Society of Anesthesiologists; July 2005.
Role of intraoperative cholangiography in avoiding bile duct injury.
Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Lights. Camera. Robot Action!
Shute N. U.S. News & World Report. January 23, 2006;140:62-63.
ACOG Committee Opinion #464: patient safety in the surgical environment.
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:786-790.
Spinal surgery and patient safety: a systems approach.
Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.
Using Six Sigma to improve patient safety in the perioperative process.
Galli BJ, Riebling N, Paraso C, Lehmann G, Yule M. Patient Saf Qual Healthc. July/August 2013;10:36-41.
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.
Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.
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