U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (27)
Diagnostic Errors (30)
Identification Errors (33)
Discontinuities, Gaps, and Hand-Off Problems (29)
Fatigue and Sleep Deprivation (4)
Medication Safety (164)
Medical Complications (55)
Nonsurgical Procedural Complications (10)
Surgical Complications (77)
Transfusion Complications (3)
Psychological and Social Complications (42)
Australia and New Zealand (20)
North America (397)
Journal Article (393)
Newspaper/Magazine Article (61)
Press Release/Announcement (5)
Special or Theme Issue (5)
Web Resource (20)
Epidemiology of Errors and Adverse Events (239)
Active Errors (147)
Latent Errors (55)
Near Miss (36)
Approach to Improving Safety
Governmental Reporting (29)
Institutional Reporting (43)
Nongovernmental Reporting (9)
Patient Disclosure (84)
Patient Complaints (23)
Never Events (27)
Allied Health Services (4)
Complementary and Alternative Medicine (1)
Health Care Providers (406)
Health Care Executives and Administrators (436)
Non-Health Care Professionals (220)
Setting of Care
Psychiatric Facilities (5)
Residential Facilities (15)
Ambulatory Care (57)
Outpatient Surgery (15)
Patient Transport (6)
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Failure to Report
Spath PL. AHRQ WebM&M [serial online]. March 2007.
Error tracking in a clinical biochemistry laboratory.
Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-site sinus surgery in otolaryngology.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2015.
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.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:405-406.
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.
Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
Check the Wristband.
Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
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.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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.
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.
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Medication errors with electronic prescribing (eP): two views of the same picture.
Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India.
Sewal RK, Singh PK, Prakash A, Kumar B, Medhi B. Int J Appl Basic Med Res. 2014;4:43-46.
SPECIAL OR THEME ISSUE
The safety and quality of health care: where are we now?
Med J Aust. 2006;184:S37-S72.
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