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United States of America
PATIENT SAFETY PRIMERS
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Safety Target
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Device-related Complications (134)
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STUDY
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
STUDY
The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.
Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.
STUDY
Consequences of inadequate sign-out for patient care.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.
STUDY
Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.
Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.
STUDY
Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.
Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.
STUDY
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.
BOOK/REPORT
HealthGrades Sixth Annual Patient Safety in American Hospitals Study.
Golden, CO: HealthGrades, Inc.; April 2009.
STUDY
Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.
Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
COMMENTARY
Quality improvement through implementation of discharge order reconciliation.
Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.
REVIEW
Suicide in the medical setting.
Ballard ED, Pao M, Henderson D, et al. Jt Comm J Qual Patient Saf. 2008;34:474-481.
STUDY
Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.
Zsenits B, Polashenski WA, Sterns RH, Brown DR IV, Moheet A. J Hosp Med. 2009;4:308-312.
STUDY
Adverse events during hospitalization: results of a patient survey.
Fowler FJ, Epstein A, Weingart SN, et al. Jt Comm J Qual Patient Saf. 2008;34:583-590.
STUDY
Tracking rates of patient safety indicators over time: lessons from the Veterans Administration.
Rosen AK, Zhao S, Rivard P, et al. Med Care. 2006;44:850-861.
STUDY
Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.
STUDY
What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.
Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].
COMMENTARY
Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.
Franco AC, Maxwell P, Green K, Barthol C. Hosp Pharm. 2009;44:776-780, 784.
STUDY
Discrepancies between home medications listed at hospital admission and reported medical conditions.
Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.
COMMENTARY
Improving heparin safety: a multidisciplinary invited conference.
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
STUDY
Improving the discharge process by embedding a discharge facilitator in a resident team.
Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.
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