U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (77)
Clinical Guideline (1)
Journal Article (56)
Newspaper/Magazine Article (21)
Web Resource (1)
Epidemiology of Errors and Adverse Events (31)
Active Errors (42)
Latent Errors (3)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (30)
Legal and Policy Approaches (12)
Error Reporting and Analysis (35)
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 (66)
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.
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.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Butcher L. Hosp Health Netw. November 2011.
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.
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.
Hospital tells of surgery on wrong side.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
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.
"It is the left eye, right?"
Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
'Wrong-site' surgical mistakes are rare, preventable.
Stein L. St. Petersburg Times. June 21, 2010.
Duplication of surgical site marking.
Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.
Using "near misses" analysis to prevent wrong-site surgery.
Yoon RS, Alaia MJ, Hutzler LH, Bosco JA III. J Healthc Qual. 2013 Aug 23; [Epub ahead of print].
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
What is Correct-Site Surgery?
American College of Surgeons.
Priority patient safety issues identified by perioperative nurses.
Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.
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