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PATIENT SAFETY PRIMERS
Root Cause Analysis
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STUDY
Preventing wrong site, procedure, and patient events using a common cause analysis.
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.
STUDY
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
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
Nature, causes and consequences of unintended events in surgical units.
van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.
COMMENTARY
The Role of the Patient in Improving Patient Safety
Gibson R. AHRQ WebM&M [serial online]. March 2007.
BOOK/REPORT
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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 craniotomy: analysis of 35 cases and systems for prevention.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473. 
COMMENTARY
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
NEWSPAPER/MAGAZINE ARTICLE
Multiple latent failures align to allow a serious drug interaction to harm a patient.
ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.
COMMENTARY
Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:547-550, 554.
STUDY
Communication errors in dispatch of air medical transport.
Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.
COMMENTARYclassic
The wrong patient.
Chassin MR, Becher EC. Ann Intern Med. 2002;136:826-833.
COMMENTARYclassic
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
COMMENTARY
Inadvertent Castration.
Calland JF. AHRQ WebM&M [serial online]. January 2004.
COMMENTARY
Environmental Safety in the OR.
Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.
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