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- Communication Improvement 6
- Education and Training 3
- Error Reporting and Analysis 3
- Human Factors Engineering
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 4
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 6
- Surgical Complications 3
- Health Care Executives and Administrators 11
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 2
Search results for ""
Tools/Toolkit > Toolkit
Englewood, CO: Colorado Foundation for Medical Care, Colorado Hospital Association, Western Alliance for Patient Safety; 2007.
This website offers information and a toolkit regarding standardizing the colors of wristbands, stickers, and placards to signify risk alert status for hospital-based patient care.
PA-PSRS Patient Saf Advis. September 2007;4:69, 73-77.
Drawing from data submitted to the Patient Safety Authority reporting system, this article documents factors involved in errors related to medication labels and package design. It also provides risk reduction strategies to minimize such errors.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.
PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50.
This failure mode and effects analysis (FMEA) explores factors contributing to near miss and adverse events related to alarm response and provides strategies to prevent monitoring failures.
PA-PSRS Patient Saf Advis. June 2008;5:53-56.
This article reports on cases of improper IV administration of sterile water, a high-alert substance, for the treatment of hypernatremia and provides risk reduction strategies for this potentially fatal error.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Tools/Toolkit > Multi-use Website
Washington State Hospital Association.
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
This article discusses adverse incidents submitted to the Pennsylvania reporting system involving neuromuscular blocking agents and shares strategies to minimize errors with this type of high-alert drug.
PA-PSRS Patient Saf Advis. June 2010;7:46-51.
This piece characterizes medication storage methods that contribute to adverse drug events and provides suggestions for improvement.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.