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Culture of Safety
PATIENT SAFETY PRIMERS
Safety Culture
Glossary
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Safety Culture:
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work...
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Safety Target
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Device-related Complications (30)
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Diagnostic Errors (20)
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Identification Errors (15)
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Discontinuities, Gaps, and Hand-Off Problems (48)
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Fatigue and Sleep Deprivation (7)
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Medication Safety (135)
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Medical Complications (107)
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Nonsurgical Procedural Complications (23)
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Surgical Complications (96)
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Epidemiology of Errors and Adverse Events (89)
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Active Errors (67)
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Latent Errors (70)
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Near Miss (16)
Approach to Improving Safety
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Culture of Safety
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Learning Organization (54)
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Institutional Patient Safety Plan (25)
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Just Culture (26)
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Target Audience
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Health Care Providers (576)
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Health Care Executives and Administrators (845)
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Non-Health Care Professionals (459)
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Patients (58)
Setting of Care
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Hospitals (548)
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COMMENTARY
Patient safety: moving the bar in prison health care standards.
Stern MF, Greifinger RB, Mellow J. Am J Public Health. 2010;100:2103-2110.
BOOK/REPORT
Advances in Patient Safety: New Directions and Alternative Approaches.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
BOOK/REPORT
Tennessee Center for Patient Safety Annual Report 2010.
Nashville, TN: Tennessee Center for Patient Safety; August 2011.
NEWSPAPER/MAGAZINE ARTICLE
Get me out alive.
Feldman R. The Washington Post. May 2, 2006:HE01.
SPECIAL OR THEME ISSUE
Interprofessional Approaches to Patient Safety.
J Interprof Care. 2006;20:455-571.
BOOK/REPORT
Advances in Patient Safety: From Research to Implementation.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
BOOK/REPORT
Patient Safety, 2nd edition.
Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.
COMMENTARY
The Preventable Harm Index: an effective motivator to facilitate the drive to zero.
Brilli RJ, McClead RE Jr, Davis T, Stoverock L, Rayburn A, Berry JC. J Pediatr. 2010;157:681-683.
REVIEW
Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.
Goeschel CA, Wachter RM, Pronovost PJ. Chest. 2010;138:171-178.
BOOK/REPORT
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.
Oakbrook Terrace, IL: The Joint Commission; September 2012.
SPECIAL OR THEME ISSUE
Patient Safety Papers 5.
Baker GR, ed. Healthc Q. 2010;13:1-136.
BOOK/REPORT
Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance.
Dublin, Ireland: Department of Health & Children, Commission on Patient Safety and Quality Assurance; 2008. ISBN: 9781406421835.
COMMENTARY
In Conversation with...J. Bryan Sexton, PhD, MA
AHRQ WebM&M [serial online]. December 2006.
SPECIAL OR THEME ISSUE
Quality of Anesthesia Care.
Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.
BOOK/REPORT
Commission of Inquiry on Hormone Receptor Testing.
Cameron M. St. John's, NL: Government of Newfoundland and Labrador; 2009. ISBN: 978551463537.
BOOK/REPORT
Patient Safety in Emergency Medicine.
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.
MEETING/CONFERENCE PROCEEDINGS
AHRQ 2008 Annual Conference.
Rockville, MD: Agency for Healthcare Research and Quality; February 2009.
MEETING/CONFERENCE PROCEEDINGS
AHRQ 2009 Annual Conference.
Rockville, MD: Agency for Healthcare Research and Quality; December 2009.
COMMENTARY
Disruptive clinician behavior: a persistent threat to patient safety.
Porto G, Lauve R. Patient Safety Qual Healthc. July/August 2006;3:16-24.
COMMENTARY
Patient safety at ten: unmistakable progress, troubling gaps.
Wachter RM. Health Aff (Millwood). 2010;29:165-173.
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