Narrow Results Clear All
- Communication between Providers
- Culture of Safety 1
- Education and Training 6
- Error Reporting and Analysis 4
- Human Factors Engineering 5
- Logistical Approaches 2
- Quality Improvement Strategies 7
- Specialization of Care 2
- Teamwork 5
- Technologic Approaches 5
- Discontinuities, Gaps, and Hand-Off Problems 6
- Identification Errors 5
- Medical Complications 1
- Medication Safety 7
- Nonsurgical Procedural Complications 1
- Surgical Complications 4
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PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Web Resource > Government Resource
Indiana State Department of Health.
This Web site provides background and information on Indiana's statewide incident reporting initiative.
PA-PSRS Patient Saf Advis. June 2007;4:29, 32-45.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Harrisburg, PA: Patient Safety Authority and Pennsylvania Patient Safety Reporting System; 2007.
This report compiles a series of interviews with patient safety officers on their role, the support needed to fulfill that role, and strategies for measuring improvement.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.
PA-PSRS Patient Saf Advis. December 2007;4:109, 112-123.
This article summarizes a state-level analysis that used site visits along with near miss and error reports to evaluate wrong-site surgeries.
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. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
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.
Journal Article > Study
Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
PA-PSRS Patient Saf Advis. September 2009;6:93-97.
This article reports on failures surrounding critical test results and describes mechanisms to standardize communication and reduce patient harm.
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. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Special or Theme Issue
Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Gao T, Gaunt MJ. PA-PSRS Patient Saf Advis. December 2013;10:125-136.
Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece identifies problems related to the medication reconciliation process and includes methods to address them.
PA-PSRS Patient Saf Advis. June 2011;8:63-69.
Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.