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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.
BOOK/REPORT
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2014.
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.
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.
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
Wrong-site sinus surgery in otolaryngology.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
COMMENTARY
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
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
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.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2006;41:405-406.
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.
REVIEW
Monitoring for medication errors in outpatient settings.
Balkrishnan R, Foss CE, Pawaskar M, Uhas AA, Feldman SR. J Dermatolog Treat. 2009;20:229-232.
NEWSPAPER/MAGAZINE ARTICLE
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
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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