U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (63)
Journal Article (48)
Newspaper/Magazine Article (16)
Epidemiology of Errors and Adverse Events (31)
Active Errors (39)
Latent Errors (4)
Near Miss (4)
Approach to Improving Safety
Quality Improvement Strategies (22)
Legal and Policy Approaches (9)
Error Reporting and Analysis (31)
Communication Improvement (34)
Human Factors Engineering (20)
Specialization of Care (1)
Logistical Approaches (2)
Culture of Safety (10)
Technologic Approaches (5)
Education and Training (13)
Health Care Providers (52)
Health Care Executives and Administrators (54)
Non-Health Care Professionals (15)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (7)
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Preventing wrong site, procedure, and patient events using a common cause analysis.
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-site sinus surgery in otolaryngology.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.
Knight N, Aucar J. Am J Surg. 2010;200:803-807.
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
Process changes to increase compliance with the Universal Protocol for bedside procedures.
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.
Medical errors in orthopaedics. Results of an AAOS member survey.
Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.
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.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
Outcome of 6 years of protocol use for preventing wrong site office surgery.
Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
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.
Patient safety in Taiwan: a survey on orthopedic surgeons.
Yang CT, Chen HH, Hou SM. J Formos Med Assoc. 2007;106:212-216.
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