U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (10)
Diagnostic Errors (5)
Identification Errors (3)
Discontinuities, Gaps, and Hand-Off Problems (17)
Fatigue and Sleep Deprivation (6)
Medication Safety (30)
Medical Complications (22)
Nonsurgical Procedural Complications (2)
Surgical Complications (21)
Transfusion Complications (1)
Psychological and Social Complications (9)
Australia and New Zealand (1)
North America (151)
Journal Article (89)
Newspaper/Magazine Article (53)
Press Release/Announcement (3)
Web Resource (1)
Epidemiology of Errors and Adverse Events (18)
Active Errors (13)
Latent Errors (15)
Near Miss (1)
Approach to Improving Safety
Health Care Providers (91)
Health Care Executives and Administrators (123)
Non-Health Care Professionals (121)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (9)
Ambulatory Care (19)
Outpatient Surgery (5)
Patient Transport (1)
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Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
Listen to the Family.
Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.
Reused devices, surgery's deadly suspects.
Klein A. The Washington Post. December 30, 2005:A3.
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
Organ donor's surgery death sparks questions.
Cohen E. CNN. April 9, 2012.
Errors with concentrated epinephrine in otolaryngology.
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.
Iglehart JK. N Engl J Med. 2008;359:2633-2635.
Developing a medication patient safety program — infrastructure and strategy.
Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
To Err Is Human — To Delay Is Deadly.
Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.
Disuse of system is cited in gaps in soldiers' care.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
Drill down with root cause analysis.
McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.
The challenges to transparency in reporting medical errors.
Paterick ZR, Paterick BB, Waterhouse BE, Paterick TE. J Patient Saf. 2009;5:205-209.
Our broken health care system and how to fix it: an essay on health law and policy.
Jost TS. Wake Forest Law Rev. 2006;41:537-618.
Spike in MR imaging accidents underscores need for regulation.
Radiological Society of North America. RSNA News; October 2010.
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