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 (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: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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.
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.
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.
Organ donor's surgery death sparks questions.
Cohen E. CNN. April 9, 2012.
The silence of the unblown whistle: the Nevada hepatitis C public health crisis.
Leary E, Diers D. Yale J Biol Med. 2013;86:79-87.
USP initiatives for the safe use of medical gases.
Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.
Health Care Comes Home: The Human Factors.
Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
Mackenzie CF. AHRQ WebM&M [serial online]. March 2004.
Adverse Events in Hospitals: Overview of Key Issues.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
Quality Advisory: Implementing a No-Charge Policy for Serious, Adverse Events.
Chicago, IL: American Hospital Association; February 12, 2008.
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.
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