U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (79)
Clinical Guideline (1)
Journal Article (58)
Newspaper/Magazine Article (21)
Web Resource (1)
Epidemiology of Errors and Adverse Events (31)
Active Errors (44)
Latent Errors (3)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (30)
Legal and Policy Approaches (12)
Error Reporting and Analysis (37)
Communication Improvement (42)
Human Factors Engineering (24)
Specialization of Care (1)
Logistical Approaches (3)
Culture of Safety (8)
Technologic Approaches (4)
Education and Training (15)
Health Care Providers (63)
Health Care Executives and Administrators (68)
Non-Health Care Professionals (16)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (8)
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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].
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.
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.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
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.
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.
Duplication of surgical site marking.
Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.
"It is the left eye, right?"
Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
Preventing wrong-site surgery in Minnesota: a 5-year journey.
Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.
Priority patient safety issues identified by perioperative nurses.
Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.
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