U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Safety and Medical Education
Device-related Complications (162)
Diagnostic Errors (137)
Identification Errors (72)
Discontinuities, Gaps, and Hand-Off Problems (466)
Fatigue and Sleep Deprivation (92)
Medication Safety (837)
Medical Complications (491)
Nonsurgical Procedural Complications (56)
Surgical Complications (303)
Transfusion Complications (20)
Psychological and Social Complications (180)
Australia and New Zealand (133)
Central and South America (5)
North America (2722)
Clinical Guideline (2)
Journal Article (2606)
Newspaper/Magazine Article (414)
Press Release/Announcement (14)
Special or Theme Issue (58)
Web Resource (92)
Epidemiology of Errors and Adverse Events (1118)
Active Errors (622)
Latent Errors (460)
Near Miss (57)
Approach to Improving Safety
Quality Improvement Strategies (877)
Legal and Policy Approaches (380)
Error Reporting and Analysis (1148)
Communication Improvement (829)
Human Factors Engineering (424)
Specialization of Care (265)
Logistical Approaches (243)
Culture of Safety (516)
Technologic Approaches (530)
Education and Training (697)
Allied Health Services (7)
Health Care Providers (2172)
Health Care Executives and Administrators (3033)
Non-Health Care Professionals (1565)
Setting of Care
General Hospitals (651)
Children’s Hospitals (79)
Specialty Hospitals (42)
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A new frontier in patient safety.
McCannon J, Berwick DM. JAMA
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2015.
The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.
Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.
Adverse Events in Hospitals: Overview of Key Issues.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
BOOSTing Care Transitions Resource Room.
Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.
Hospital Reporting Program.
Portland, OR: Oregon Patient Safety Commission.
African Partnerships for Patient Safety.
Geneva, Switzerland: WHO Patient Safety, World Health Organization.
Tennessee Center for Patient Safety.
National trends in patient safety for four common conditions, 2005–2011.
Wang Y, Eldridge N. Metersky ML, et al. N Engl J Med. 2014;370:341-351.
Hospital patient safety grades may misrepresent hospital performance.
Hwang W, Derk J, LaClair M, Paz H. J Hosp Med. 2014;9:111-115.
Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.
Vaida AJ, Lamis RL, Smetzer JL, Kenward K, Cohen MR. Jt Comm J Qual Patient Saf. 2014;40:51-67.
Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice.
Cortes-Penfield N. Am J Public Health. 2014;104:2060-2065.
2013 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.
Joint Commission. January 27, 2014.
Variation in Patient Safety Outcomes and the Importance of Being Informed.
Golden, CO: Healthgrades; 2013.
The next organizational challenge: finding and addressing diagnostic error.
Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. Jt Comm J Qual Patient Saf. 2014;40:102-110.
Variability in the measurement of hospital-wide mortality rates.
Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand SL. N Engl J Med. 2010;363:2530-2539.
Common formats for patient safety data collection and event reporting.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.
Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.
How much diagnostic safety can we afford, and how should we decide? A health economics perspective.
Newman-Toker DE, McDonald KM, Meltzer DO. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
"That was a close call": endorsing a broad definition of near misses in health care.
Marks CM, Kasda E, Paine L, Wu AW. Jt Comm J Qual Patient Saf. 2013;39:475-479.
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