PATIENT SAFETY PRIMERS
Diagnostic Errors (4)
Discontinuities, Gaps, and Hand-Off Problems (4)
Medication Safety (8)
Medical Complications (3)
Psychological and Social Complications (3)
North America (22)
Journal Article (20)
Newspaper/Magazine Article (5)
Web Resource (1)
Epidemiology of Errors and Adverse Events (9)
Active Errors (5)
Latent Errors (2)
Near Miss (2)
Approach to Improving Safety
Quality Improvement Strategies (9)
Legal and Policy Approaches (3)
Error Reporting and Analysis (12)
Communication Improvement (3)
Human Factors Engineering (1)
Specialization of Care (2)
Logistical Approaches (2)
Culture of Safety (4)
Technologic Approaches (1)
Education and Training (2)
Health Care Providers (23)
Health Care Executives and Administrators (23)
Non-Health Care Professionals (6)
Setting of Care
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Approved: no new National Patient Safety Goals, only minor revisions for 2011.
Jt Comm Perspect. August 2010;30:6-7.
Sentinel Event Program.
Division of Licensing and Regulatory Services, Maine Department of Health and Human Services.
Approved: 2010 National Patient Safety Goals.
Jt Comm Perspect. October 2009;29:1, 20-31.
Improving Communication During Transitions of Care.
Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations.
Testimony before the Permanent Subcommittee on Investigations of the Senate Committee of Governmental Affairs, 108th Cong, 1st Sess (June 11, 2003) (statement of Carolyn M. Clancy, MD).
Safety in Doses.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
Hospital infections hard to gauge.
Hamill SD. Pittsburgh Post-Gazette. April 18, 2010:A1.
Using root cause analysis to reduce falls with injury in the psychiatric unit.
Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.
Prohibition of Excessive Overtime for Nurses Act.
The General Assembly of Pennsylvania. HB957 (2005).
Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.
Quigley PA, Barnett SD, Bulat T, Friedman Y. J Nurs Care Qual. 2014;29:51-59.
Medication safety in a psychiatric hospital.
Rothschild JM, Mann K, Keohane CA, et al. Gen Hosp Psychiatry. 2007;29:156-162.
Diagnostic errors and temporal stability in bipolar disorder.
López J, Baca E, Botillo C, et al. Actas Esp Psiquiatr. 2008;36:205-209.
Medication errors in mental healthcare: a systematic review.
Maidment ID, Lelliott P, Paton C. Qual Saf Health Care. 2006;15:409-413.
Toward understanding errors in inpatient psychiatry: a qualitative inquiry.
Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.
Global priorities for patient safety research.
Bates DW, Larizgoitia I, Prasopa-Plaizier N, Jha AK; Research Priority Setting Working Group of the WHO World Alliance for Patient Safety. BMJ. 2009;338:b1775.
Learning from the best.
Grantham D. Behav Healthc. April 2010;30:22-24.
Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards.
Mills PD, King LA, Watts BV, Hemphill RR. Gen Hosp Psychiatry. 2013;35:528-536.
Code Blue—Where To?
Adams BD. AHRQ WebM&M [serial online]. October 2007.
Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.
Jayaram G, Doyle D, Steinwachs D, Samuels J. J Psychiatr Pract. 2011;17:81–88.
What near misses tell us about risk and safety in mental health care.
Jeffs L, Rose D, Macrae C, Maione M, Macmillan KM. J Psychiatr Ment Health Nurs. 2012;19:430-437.
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