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PATIENT SAFETY PRIMERS
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 (23)

•Diagnostic Errors (18)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (43)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (118)

•Medical Complications (85)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (84)

•Transfusion Complications (1)

•Psychological and Social Complications (37)

Origin/Sponsor

•Australia and New Zealand (21)

•Central and South America (3)

•Europe (127)

•North America (566)

Resource Types

•Audiovisual (6)

•Book/Report (77)

•Journal Article (511)

•Legislation/Regulation (9)

•Meeting/Conference (14)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (52)

•Press Release/Announcement (3)

•Special or Theme Issue (23)

•Tools/Toolkit (21)

•Web Resource (24)

Error Types

•Epidemiology of Errors and Adverse Events (81)

•Active Errors (52)

•Latent Errors (54)

•Near Miss (11)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (23)

•Institutional Patient Safety Plan (11)

•Just Culture (12)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (1)

•Dentistry (4)

•Medicine (419)

•Nursing (75)

•Pharmacy (26)

Target Audience

•Health Care Providers (513)

•Health Care Executives and Administrators (689)

•Non-Health Care Professionals (410)

•Patients (38)

Setting of Care

•Hospitals (433)

•Psychiatric Facilities (4)

•Residential Facilities (28)

•Ambulatory Care (61)

•Outpatient Surgery (5)

•Patient Transport (7)

1 - 20 of 759

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STUDY

Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.

Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.

STUDY

Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety.

Castle NG, Wagner LM, Perera S, Ferguson JC, Handler SM. J Patient Saf. 2010;6:59-67.

STUDY

Nurse aides' ratings of the resident safety culture in nursing homes.

Castle NG. Int J Qual Health Care. 2006;18:370-6.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

STUDY

Organizational climate determinants of resident safety culture in nursing homes.

Arnetz JE, Zhdanova LS, Elsouhag D, Lichtenberg P, Luborsky MR, Arnetz BB. Gerontologist. 2011;51:739-749.

COMMENTARY

Lesar TS. AHRQ WebM&M [serial online]. November 2003.

STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

TOOLKIT

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.

STUDY

Measuring administrators' and direct care workers' perceptions of the safety culture in assisted living facilities.

Castle NG, Wagner LM, Sonon K, Ferguson-Rome JC. Jt Comm J Qual Patient Saf. 2012;38:375-385.

STUDY

Measuring safety climate in elderly homes.

Yeung KC, Chan CC. J Safety Res. 2012;43:9-20.

STUDY

Nursing home administrators' opinions of the resident safety culture in nursing homes.

Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

MEASUREMENT TOOL/INDICATOR

Survey User's Guide: Nursing Home Survey on Patient Safety Culture.

Sorra J, Franklin M, Streagle S. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0060.

STUDY

Organizational and cultural changes for providing safe patient care.

Odwazny R, Hasler S, Abrams R, McNutt R. Qual Manag Health Care. 2005;14:132-143.

STUDY

Patient safety in surgery.

Makary MA, Sexton JB, Freischlag JA, et al. Ann Surg. 2006;243:628-635.

COMMENTARY

Using medical-error reporting to drive patient safety efforts.

Stow J. AORN J. 2006;84:406-408, 411-414, 417-420.

MEETING/CONFERENCE PROCEEDINGS

A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing.

Texas Medical Institute of Technology. June 16, 2011.

COMMENTARY classic

classic

Creating an integrated patient safety team.

Gandhi TK, Graydon-Baker E, Barnes JN, et al. Jt Comm J Qual Saf. 2003;29:383-390.

COMMENTARY classic

classic

Fixing healthcare from the inside, today.

Spear SJ. Harv Bus Rev. September 2005;83:78-91.

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