PATIENT SAFETY PRIMERS
Device-related Complications (9)
Diagnostic Errors (4)
Identification Errors (7)
Discontinuities, Gaps, and Hand-Off Problems (9)
Medication Safety (17)
Medical Complications (13)
Nonsurgical Procedural Complications (5)
Surgical Complications (17)
Australia and New Zealand (6)
North America (44)
Journal Article (49)
Newspaper/Magazine Article (10)
Epidemiology of Errors and Adverse Events (20)
Active Errors (22)
Latent Errors (5)
Near Miss (2)
Approach to Improving Safety
Health Care Providers (54)
Health Care Executives and Administrators (53)
Non-Health Care Professionals (20)
Setting of Care
Ambulatory Care (1)
Outpatient Surgery (3)
Patient Transport (2)
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Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.
Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.
Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.
Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.
The ability of intensive care units to maintain zero central line–associated bloodstream infections.
Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.
Eliminating CLABSI: A National Patient Safety Imperative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.
Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.
Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.
Another tragic parenteral nutrition compounding error.
ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.
Central Line Clot.
Randolph AG. AHRQ WebM&M [serial online]. May 2003.
Evaluating an evidence-based bundle for preventing surgical site infection.
Anthony T, Murray BW, Sum-Ping JT, et al. Arch Surg. 2011;146:263-269.
Trauma resuscitation errors and computer-assisted decision support.
Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.
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.
Towards safer neonatal transfer: the importance of critical incident review.
Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.
Ferrari's Formula One handovers and handovers from surgery to intensive care.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.
Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.
Reducing inappropriate diagnostic practice through education and decision support.
Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.
Implementing a systematic response to medication errors.
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
White CM, Statile AM, Conway PH, et al. Pediatrics. 2012;129:e1042-e1050.
Effectiveness of an information technology intervention to improve prophylactic antibacterial use in the postoperative period.
Haynes K, Linkin DR, Fishman NO, et al. J Am Med Inform Assoc. 2011;18:164-168.
Postoperative sepsis in the United States.
Vogel TR, Dombrovskiy VY, Carson JL, Graham AM, Lowry SF. Ann Surg. 2010;252:1065-1071.
A Mid-Summer Fog
Braddock CH. AHRQ WebM&M [serial online]. November 2008.
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