U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Retained Surgical Instruments and Sponges (63)
Wrong-Site Surgery (74)
Australia and New Zealand (4)
North America (179)
Clinical Guideline (3)
Journal Article (153)
Newspaper/Magazine Article (43)
Special or Theme Issue (2)
Web Resource (4)
Epidemiology of Errors and Adverse Events (63)
Active Errors (101)
Latent Errors (10)
Near Miss (5)
Approach to Improving Safety
Quality Improvement Strategies (55)
Legal and Policy Approaches (25)
Error Reporting and Analysis (76)
Communication Improvement (55)
Human Factors Engineering (61)
Specialization of Care (3)
Logistical Approaches (4)
Culture of Safety (12)
Technologic Approaches (20)
Education and Training (30)
Health Care Providers (157)
Health Care Executives and Administrators (154)
Non-Health Care Professionals (57)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (7)
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'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Surgical checklists: a systematic review of impacts and implementation.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
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.
Collegiality vs. Competence
Sagin T. AHRQ WebM&M [serial online]. March 2006.
Role of intraoperative cholangiography in avoiding bile duct injury.
Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.
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.
Surgery fires spur need for new guidelines.
Collins D. Associated Press [MSNBC]. July 26, 2007.
Do cell phones belong in the operating room?
Luthra S. Kaiser Health News. July 14, 2015.
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.
When the bone flap hits the floor.
Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.
Spinal surgery and patient safety: a systems approach.
Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.
Butcher L. Hosp Health Netw. November 2011.
Save a brain, make a checklist.
Hamblin J. The Atlantic. March 17, 2014.
Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.
Moorthy K, Munz Y, Forrest D, et al. Ann Surg. 2006;244:139-147.
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.
Surgical count practice variability and the potential for retained surgical items.
Edel EM. AORN J. 2012;95:228-238.
Clinic sued over towel left in patient.
McCarty JF. Plain Dealer. January 16, 2007:A1.
Tracking intraoperative complications.
Platz J, Hyman N. J Am Coll Surg. 2012;215:519-523.
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