PATIENT SAFETY PRIMERS
Device-related Complications (9)
Diagnostic Errors (4)
Identification Errors (7)
Discontinuities, Gaps, and Hand-Off Problems (8)
Medication Safety (17)
Medical Complications (13)
Nonsurgical Procedural Complications (5)
Surgical Complications (17)
Australia and New Zealand (6)
North America (43)
Journal Article (48)
Newspaper/Magazine Article (10)
Epidemiology of Errors and Adverse Events (20)
Active Errors (21)
Latent Errors (4)
Near Miss (2)
Approach to Improving Safety
Health Care Providers (53)
Health Care Executives and Administrators (52)
Non-Health Care Professionals (19)
Setting of Care
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.
Elimination of central-venous-catheter-related bloodstream infections from the intensive care unit.
Longmate AG, Ellis KS, Boyle L, et al. BMJ Qual Saf. 2011;20:174-180.
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.
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.
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.
National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.
Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.
Central Line Clot.
Randolph AG. AHRQ WebM&M [serial online]. May 2003.
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.
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.
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.
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.
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.
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.
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.
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.
Postoperative sepsis in the United States.
Vogel TR, Dombrovskiy VY, Carson JL, Graham AM, Lowry SF. Ann Surg. 2010;252:1065-1071.
Does user-centred design affect the efficiency, usability and safety of CPOE order sets?
Chan J, Shojania KG, Easty AC, Etchells EE. J Am Med Inform Assoc. 2011;18:276-281.
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