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.
Trauma resuscitation errors and computer-assisted decision support.
Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.
Central Line Clot.
Randolph AG. AHRQ WebM&M [serial online]. May 2003.
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.
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.
Ferrari's Formula One handovers and handovers from surgery to intensive care.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
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.
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.
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.
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.
Identifying opportunities for quality improvement in surgical site infection prevention.
Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.
Prevention of intravenous drug incompatibilities in an intensive care unit.
Bertsche T, Mayer Y, Stahl R, et al. Am J Health Syst Pharm. 2008;65:1834-1840.
Implementing a systematic response to medication errors.
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
Outcome of 6 years of protocol use for preventing wrong site office surgery.
Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.
A Mid-Summer Fog
Braddock CH. AHRQ WebM&M [serial online]. November 2008.
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