U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Device-related Complications (10)
Diagnostic Errors (5)
Identification Errors (3)
Discontinuities, Gaps, and Hand-Off Problems (17)
Fatigue and Sleep Deprivation (6)
Medication Safety (29)
Medical Complications (21)
Nonsurgical Procedural Complications (2)
Surgical Complications (21)
Transfusion Complications (1)
Psychological and Social Complications (9)
Australia and New Zealand (1)
North America (150)
Journal Article (88)
Newspaper/Magazine Article (53)
Press Release/Announcement (3)
Web Resource (1)
Epidemiology of Errors and Adverse Events (17)
Active Errors (13)
Latent Errors (15)
Near Miss (1)
Approach to Improving Safety
Health Care Providers (90)
Health Care Executives and Administrators (122)
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: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
Organ donor's surgery death sparks questions.
Cohen E. CNN. April 9, 2012.
Never Events: Framework 2009/10.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
Carpenter D. Hosp Health Netw. November 2007;81:34-38.
Listen to the Family.
Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.
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.
No pay for "never event" errors becoming standard.
O'Reilly KB. American Medical News. January 7, 2008.
Reused devices, surgery's deadly suspects.
Klein A. The Washington Post. December 30, 2005:A3.
Errors with concentrated epinephrine in otolaryngology.
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
Serious Reportable Events in Healthcare—2011 Update.
Washington, DC: National Quality Forum; 2011. ISBN: 9780982842188.
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.
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.
Opportunities and Recommendations for State–Federal Coordination to Improve Health System Performance: A Focus on Patient Safety.
Buxbaum J. Portland, ME: National Academy for State Health Policy; January 2010.
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
USP initiatives for the safe use of medical gases.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
Mackenzie CF. AHRQ WebM&M [serial online]. March 2004.
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