U.S. Department of Health & Human Services
Culture of Safety
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work...
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Device-related Complications (30)
Diagnostic Errors (18)
Identification Errors (16)
Discontinuities, Gaps, and Hand-Off Problems (44)
Fatigue and Sleep Deprivation (5)
Medication Safety (116)
Medical Complications (98)
Nonsurgical Procedural Complications (21)
Surgical Complications (92)
Transfusion Complications (2)
Psychological and Social Complications (44)
Australia and New Zealand (15)
Central and South America (2)
North America (767)
Clinical Guideline (1)
Journal Article (584)
Newspaper/Magazine Article (87)
Press Release/Announcement (4)
Special or Theme Issue (33)
Web Resource (29)
Epidemiology of Errors and Adverse Events (96)
Active Errors (76)
Latent Errors (97)
Near Miss (12)
Approach to Improving Safety
Culture of Safety
Learning Organization (13)
Red Rules (2)
Institutional Patient Safety Plan (10)
Just Culture (14)
Allied Health Services (3)
Health Care Providers (594)
Health Care Executives and Administrators (753)
Non-Health Care Professionals (421)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (24)
Ambulatory Care (61)
Outpatient Surgery (4)
Patient Transport (10)
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A hospital races to learn lessons of Ferrari pit stop.
Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].
Pediatric patient safety in the prehospital/emergency department setting.
Barata IA, Benjamin LS, Mace SE, Herman MI, Goldman RD. Pediatr Emerg Care. 2007;23:412-418.
Patient Safety in Emergency Medicine.
Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.
The Emergency Medical Services Safety Attitudes Questionnaire.
Patterson PD, Huang DT, Fairbanks RJ, Wang HE. Am J Med Qual. 2010;25:109-115.
SPECIAL OR THEME ISSUE
Safety in EMS.
Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.
Pediatric patient safety in emergency departments: unit characteristics and staff perceptions.
Shaw KN, Ruddy RM, Olsen CS, et al; Pediatric Emergency Care Applied Research Network. Pediatrics. 2009;124:485-493.
Pediatric Patient Safety in the Emergency Department.
Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.
Creating a culture of safety in the emergency department: the value of teamwork training.
Jones F, Podila P, Powers C. J Nurs Adm. 2013;43:194-200.
Strategy for a National EMS Culture of Safety.
Irving, TX: American College of Emergency Physicians; 2013.
Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.
An implementation strategy for a multicenter pediatric rapid response system in Ontario.
Lobos A, Costello J, Gilleland J, Gaiteiro R, Kotsakis A; The Ontario Pediatric Critical Care Response Team Collaborative. Jt Comm J Qual Patient Saf. 2010;36:271-280.
Radiation risks of diagnostic imaging.
Sentinel Event Alert #47. August 24, 2011.
Compliance with guidelines to prevent surgical site infections: as simple as 1-2-3?
Meeks DW, Lally KP, Carrick MM, et al. Am J Surg. 2011;201:76-83.
SPECIAL OR THEME ISSUE
Patient Safety and Quality.
Lyndon A, Simpson KR, Bakewell-Sachs S, eds. J Perinat Neonat Nurs. 2010;24:1-89.
One intensive care nursery's experience with enhancing patient safety.
Alton M, Mericle J, Brandon D. Adv Neonatal Care. 2006;6:112-119.
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.
Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.
Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.
Creating an integrated patient safety team.
Gandhi TK, Graydon-Baker E, Barnes JN, et al. Jt Comm J Qual Saf. 2003;29:383-390.
Safer Hospital Care: Strategies for Continuous Innovation.
Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.
Delay in Initiating Antibiotics Leads to Fatal Error.
Bellini LM. AHRQ WebM&M [serial online]. February 2004.
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