U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
North America (66)
Journal Article (79)
Newspaper/Magazine Article (10)
Epidemiology of Errors and Adverse Events (33)
Active Errors (67)
Latent Errors (8)
Approach to Improving Safety
Quality Improvement Strategies (26)
Legal and Policy Approaches (7)
Error Reporting and Analysis (27)
Communication Improvement (20)
Human Factors Engineering (6)
Specialization of Care (6)
Logistical Approaches (2)
Culture of Safety (3)
Technologic Approaches (10)
Education and Training (21)
Health Care Providers (85)
Health Care Executives and Administrators (53)
Non-Health Care Professionals (30)
Setting of Care
Psychiatric Facilities (3)
Ambulatory Care (18)
Patient Transport (1)
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The impact of clinically undiagnosed injuries on survival estimates.
Gedeborg R, Thiblin I, Byberg L, Wernroth L, Michaëlsson K. Crit Care Med. 2009;37:449-455.
Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis.
Singh H, Daci K, Petersen LA, et al. Am J Gastroenterol. 2009;104:2543-2554.
Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.
Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.
Characteristics of patients misdiagnosed with Alzheimer's disease and their medication use: an analysis of the NACC-UDS database.
Gaugler JE, Ascher-Svanum H, Roth DL, Fafowora T, Siderowf A, Beach TG. BMC Geriatr. 2013;13:137.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study.
Derkx HP, Rethans JE, Muijtjens AM, et al. BMJ. 2008;337:a1264.
Adams JG. AHRQ WebM&M [serial online]. June 2003.
Diagnostic errors and temporal stability in bipolar disorder.
López J, Baca E, Botillo C, et al. Actas Esp Psiquiatr. 2008;36:205-209.
Preventable morbidity at a mature trauma center.
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
Redesigning surgical decision making for high-risk patients.
Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.
Delirium or Dementia?
Rudolph JL. AHRQ WebM&M [serial online]. May 2009.
Preventing the tragedy of misdiagnosis.
Landro L. Wall Street Journal (Eastern edition). November 29, 2006: D1-D5. [Reprinted on Post-gazette.com].
National Institutes of Health, National Cancer Institute. September 1–3, 2015; The National Institutes of Health, Natcher Building, Bethesda, MD.
The pursuit of better diagnostic performance: a human factors perspective.
Henriksen K, Brady J. BMJ Qual Saf. 2013;22(supp 2):1-5.
Coming Up Short
Hochberg Z. AHRQ WebM&M [serial online]. October 2008.
Fixing broken bones and broken homes: domestic violence as a patient safety issue.
Cohn F, Rudman WJ. Jt Comm J Qual Saf. 2004;30:636-646.
Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology.
Vioque SM, Kim PK, McMaster J, et al. Am J Surg. 2014;208:187-194.
Failure to Latch
Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
An Outpatient “Zebra”
Berkowitz L. AHRQ WebM&M [serial online]. January 2006.
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