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Audit and Feedback
PATIENT SAFETY PRIMERS
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Device-related Complications (16)
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NEWSPAPER/MAGAZINE ARTICLE
Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.
ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.
STUDY
A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients.
Mitchell IA, McKay H, Van Leuvan C, et al. Resuscitation. 2010;81:658-666.
STUDY
Impact of a comprehensive patient safety strategy on obstetric adverse events.
Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009 May;200:492.e1-8.
STUDY
A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.
Lander L, Roberson DW, Plummer KM, Forbes PW, Healy GB, Shah RK. Otolaryngol Head Neck Surg. 2010;143:480-486.
BOOK/REPORT
Safer Care for the Acutely Ill Patient: Learning from Serious Incidents.
Thomson R, Luettel D, Healey F, Scobie S. London, UK: National Patient Safety Agency; 2007. ISBN: 9780955634055.
STUDY
Trauma resuscitation errors and computer-assisted decision support.
Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.
STUDY
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.
Byrnes MC, Schuerer DJ, Schallom ME, et al. Crit Care Med. 2009; 37:2775-2781.
STUDY
Patient characteristics and the occurrence of never events.
Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.
STUDY
Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.
O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.
STUDY
Inability of providers to predict unplanned readmissions.
Allaudeen N, Schnipper JL, Orav EJ, Wachter RM, Vidyarthi AR. J Gen Intern Med. 2011;26:771-776.
STUDY
Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.
van Walraven C, Jennings A, Taljaard M, et al. CMAJ. 2011;183:E1067-E1072.
STUDY
Increasing patient safety event reporting in 2 intensive care units: A prospective interventional study.
Ilan R, Squires M, Panopoulos C, Day A. J Crit Care. 2011;26:e11-e18.
COMMENTARY
Managing the adverse event occurring during elective, ambulatory pediatric surgery.
Skarsgard ED. Semin Pediatr Surg. 2009;18:122-124.
STUDY
Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.
Pines JM, Mongelluzzo J, Hilton JA, et al. Ann Emerg Med. 2010;56:253-257.
STUDY
The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events.
van Gaal BG, Schoonhoven L, Hulscher ME, et al. BMC Health Serv Res. 2009;9:58.
STUDY
Patient record review of the incidence, consequences, and causes of diagnostic adverse events.
Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.
REVIEW
Patient safety systems in the primary health care of diabetes—a story of missed opportunities?
Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.
STUDY
Adverse drug events in the outpatient setting: an 11-year national analysis.
Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.
STUDY
Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.
Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.
STUDY
Association between license status and medication errors.
Conroy S. Arch Dis Child. 2011;96:305-306.
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