U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (34)
Diagnostic Errors (50)
Identification Errors (24)
Discontinuities, Gaps, and Hand-Off Problems (98)
Fatigue and Sleep Deprivation (4)
Medication Safety (168)
Medical Complications (40)
Nonsurgical Procedural Complications (14)
Surgical Complications (47)
Transfusion Complications (3)
Psychological and Social Complications (31)
Australia and New Zealand (20)
North America (414)
Journal Article (414)
Newspaper/Magazine Article (63)
Press Release/Announcement (9)
Special or Theme Issue (6)
Web Resource (12)
Approach to Improving Safety
Quality Improvement Strategies (127)
Legal and Policy Approaches (75)
Error Reporting and Analysis (167)
Communication Improvement (167)
Human Factors Engineering (108)
Specialization of Care (16)
Logistical Approaches (40)
Culture of Safety (93)
Technologic Approaches (116)
Education and Training (121)
Allied Health Services (5)
Health Care Providers (441)
Health Care Executives and Administrators (421)
Non-Health Care Professionals (311)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (9)
Ambulatory Care (75)
Outpatient Surgery (4)
Patient Transport (5)
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Failure to Report
Spath PL. AHRQ WebM&M [serial online]. March 2007.
Error tracking in a clinical biochemistry laboratory.
Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.
Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.
van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.
Nature, causes and consequences of unintended events in surgical units.
van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2015.
Check the Wristband.
Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:405-406.
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
SPECIAL OR THEME ISSUE
Special Issue: Patient Safety.
Explaining ethnic disparities in patient safety: a qualitative analysis.
Suurmond J, Uiters E, De Bruijne MC, Stronks K, Essink-Bot ML. Am J Public Health. 2010;100 (suppl 1):S113-117.
Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention.
Yang A, Grissinger M. PA-PSRS Patient Saf Advis. 2013;10:41-49.
Mortality related to anaesthesia in France: analysis of deaths related to airway complications.
Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Anaesthesia. 2009;64:366-370.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
Medical errors recovered by critical care nurses.
Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
Patterson ES. AHRQ WebM&M [serial online]. November 2008.
Crossing the Line.
Feldman JP, Gould MK. AHRQ WebM&M [serial online]. March 2004.
Insufficient communication about medication use at the interface between hospital and primary care.
Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.
Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network.
Phillips RL, Dovey SM, Graham D, Elder NC, Hickner JM. J Patient Saf. 2006;2:140-146.
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