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Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (19)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (46)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (135)

•Medical Complications (107)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (93)

•Transfusion Complications (3)

•Psychological and Social Complications (40)

Origin/Sponsor

•Australia and New Zealand (19)

•Central and South America (3)

•Europe (101)

•North America (784)

Resource Types

•Audiovisual (10)

•Book/Report (107)

•Clinical Guideline (1)

•Journal Article (596)

•Legislation/Regulation (11)

•Meeting/Conference (17)

•Newspaper/Magazine Article (93)

•Press Release/Announcement (4)

•Special or Theme Issue (34)

•Tools/Toolkit (17)

•Web Resource (27)

Error Types

•Epidemiology of Errors and Adverse Events (88)

•Active Errors (64)

•Latent Errors (65)

•Near Miss (14)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (47)

•Red Rules (2)

•Institutional Patient Safety Plan (23)

•Just Culture (20)

Clinical Areas

•Allied Health Services (4)

•Dentistry (5)

•Medicine (518)

•Nursing (91)

•Pharmacy (27)

Target Audience

•Health Care Providers (569)

•Health Care Executives and Administrators (816)

•Non-Health Care Professionals (426)

•Patients (58)

Setting of Care

•Hospitals (539)

•Psychiatric Facilities (3)

•Residential Facilities (25)

•Ambulatory Care (57)

•Outpatient Surgery (4)

•Patient Transport (8)

1 - 20 of 939

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STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

PRESS RELEASE/ANNOUNCEMENT classic

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AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

STUDY

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

PRESS RELEASE/ANNOUNCEMENT

The MacArthur Fellows Program: Peter Pronovost.

The John D. and Catherine T. MacArthur Foundation. September 23, 2008.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

STUDY

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. Qual Saf Health Care. 2008;17:25-30.

STUDY

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An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.

COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

COMMENTARY

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Pronovost PJ. Jt Comm J Qual Patient Saf. 2010;36:525-528.

COMMENTARY

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

Goeschel CA, Holzmueller CG, Berenholtz SM, et al. Jt Comm J Qual Patient Saf. 2010;36:519-524.

STUDY

Nurses' perceptions of error communication and reporting in the intensive care unit.

Elder NC, Brungs SM, Nagy M, Kudel I, Render ML. J Patient Saf. 2008;4:162-168.

NEWSPAPER/MAGAZINE ARTICLE classic

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The checklist.

Gawande A. The New Yorker. December 10, 2007;83:86-95.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

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Improving patient safety in intensive care units in Michigan.

Pronovost PJ, Berenholtz SM, Goeschel C, et al. J Crit Care. 2008;23:207-221.

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