PATIENT SAFETY PRIMERS
Device-related Complications (4)
Discontinuities, Gaps, and Hand-Off Problems (13)
Medication Safety (24)
Medical Complications (65)
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Epidemiology of Errors and Adverse Events (32)
Active Errors (8)
Latent Errors (3)
Approach to Improving Safety
Unit Based Safety Teams (15)
Rapid Response Team (117)
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Setting of Care
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Clinical triggers: an alternative to a rapid response team.
Moldenhauer K, Sabel A, Chu ES, Mehler PS. Jt Comm J Qual Patient Saf. 2009;35:164-174.
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction.
ED Manag. 2011;23:78-80.
Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.
Flood KL, Carroll MB, Le CV, Brown CJ. Am J Geriatr Pharmacother. 2009;7:151-158.
Reduction in hospital mortality over time in a hospital without a pediatric medical emergency team: limitations of before-and-after study designs.
Joffe AR, Anton NR, Burkholder SC. Arch Pediatr Adolesc Med. 2011;165:419-423.
Creating an integrated patient safety team.
Gandhi TK, Graydon-Baker E, Barnes JN, et al. Jt Comm J Qual Saf. 2003;29:383-390.
Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM).
Cooper S, Cant R, Porter J, et al. Resuscitation. 2010;81:446-452.
A pediatric medical emergency team manages a complex child with hypoxia and a worried parent.
Shilkofski NA, Hunt EA. Jt Comm J Qual Patient Saf. 2007;33:236-241.
Hospitals try to break a deadly 'code.'
Kowalczyk L. The Boston Globe. November 27, 2005:A1.
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
Epidemiology and patient outcome after medical emergency team calls triggered by atrial fibrillation.
Schneider A, Calzavacca P, Jones D, Bellomo R. Resuscitation. 2011;82:410-414.
The effect of multidisciplinary care teams on intensive care unit mortality.
Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. Arch Intern Med. 2010;170:369-376.
Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.
Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.
Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.
A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.
Galhotra S, Devita MA, Dew MA, Simmons RL. Qual Saf Health Care. 2010;19:e38.
How-to Guide: Multidisciplinary Rounds.
Cambridge, MA: Institute for Healthcare Improvement; February 2010.
Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.
Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.
Implementation of Condition Help: family teaching and evaluation of family understanding.
Hueckel RM, Mericle JM, Frush K, Martin PL, Champagne MT. J Nurs Care Qual. 2012;27:176-181.
Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system.
Hravnak M, Edwards L, Clontz A, Valenta C, DeVita MA, Pinsky MR. Arch Intern Med. 2008;168:1300-1308.
Using Medical Emergency Teams to detect preventable adverse events.
Iyengar A, Baxter A, Forster AJ. Crit Care. 2009;13:R126.
Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital.
Wang GS, Erwin N, Zuk J, Henry DB, Dobyns EL. J Hosp Med. 2011;6:131-135.
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