U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (21)
Diagnostic Errors (9)
Identification Errors (71)
Discontinuities, Gaps, and Hand-Off Problems (59)
Fatigue and Sleep Deprivation (23)
Medication Safety (41)
Medical Complications (32)
Nonsurgical Procedural Complications (6)
Surgical Complications (708)
Transfusion Complications (2)
Psychological and Social Complications (42)
Australia and New Zealand (17)
North America (632)
Clinical Guideline (3)
Journal Article (672)
Newspaper/Magazine Article (81)
Press Release/Announcement (1)
Special or Theme Issue (13)
Web Resource (18)
Epidemiology of Errors and Adverse Events (235)
Active Errors (211)
Latent Errors (59)
Near Miss (17)
Approach to Improving Safety
Quality Improvement Strategies (163)
Legal and Policy Approaches (52)
Error Reporting and Analysis (213)
Communication Improvement (239)
Human Factors Engineering (213)
Specialization of Care (19)
Logistical Approaches (42)
Culture of Safety (79)
Technologic Approaches (62)
Education and Training (178)
Health Care Providers (584)
Health Care Executives and Administrators (621)
Non-Health Care Professionals (266)
Setting of Care
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Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
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].
The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.
Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.
Tomorrow's operating room to harness Net, RFID.
Olsen S. CNET News.com; October 19, 2005.
Surgical specimen identification errors: a new measure of quality in surgical care.
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.
Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.
Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
Butcher L. Hosp Health Netw. November 2011.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Surgical team behaviors and patient outcomes.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.
Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.
Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.
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.
Video technology to advance safety in the operating room and perioperative environment.
Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.
Surgical never events and contributing human factors.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;58:515-521.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
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