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PATIENT SAFETY PRIMERS
Never Events
Systems Approach
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COMMENTARY
Failure to Report
Spath PL. AHRQ WebM&M [serial online]. March 2007.
STUDY
Error tracking in a clinical biochemistry laboratory.
Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.
STUDYclassic
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
COMMENTARY
Internally-developed online adverse drug reaction and medication error reporting systems.
Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.
STUDY
Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
STUDY
The incidence and nature of prescribing and medication administration errors in paediatric inpatients.
Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.
BOOK/REPORT
Adverse Health Events in Minnesota: Tenth Annual Public Report.
St. Paul, MN: Minnesota Department of Health; January 2014.
STUDY
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:405-406.
COMMENTARY
Check the Wristband.
Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.
FACT SHEET/FAQS
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
COMMENTARY
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
STUDY
Wrong-site sinus surgery in otolaryngology.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
BOOK/REPORT
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2014.
STUDY
Impact of a comprehensive safety initiative on patient-controlled analgesia errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
STUDY
A comparison of voluntarily reported medication errors in intensive care and general care units.
Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.
STUDY
Preventable morbidity at a mature trauma center.
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
COMMENTARY
ISMP medication error report analysis.
Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355. 
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