U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Safety and Medical Education
Device-related Complications (156)
Diagnostic Errors (127)
Identification Errors (71)
Discontinuities, Gaps, and Hand-Off Problems (458)
Fatigue and Sleep Deprivation (91)
Medication Safety (815)
Medical Complications (488)
Nonsurgical Procedural Complications (55)
Surgical Complications (300)
Transfusion Complications (20)
Psychological and Social Complications (161)
Australia and New Zealand (129)
Central and South America (5)
North America (2644)
Clinical Guideline (2)
Journal Article (2516)
Newspaper/Magazine Article (407)
Press Release/Announcement (14)
Special or Theme Issue (56)
Web Resource (92)
Epidemiology of Errors and Adverse Events (1030)
Active Errors (604)
Latent Errors (460)
Near Miss (55)
Approach to Improving Safety
Quality Improvement Strategies (867)
Legal and Policy Approaches (379)
Error Reporting and Analysis (1103)
Communication Improvement (818)
Human Factors Engineering (401)
Specialization of Care (264)
Logistical Approaches (243)
Culture of Safety (512)
Technologic Approaches (517)
Education and Training (682)
Allied Health Services (5)
Health Care Providers (2149)
Health Care Executives and Administrators (2948)
Non-Health Care Professionals (1549)
Setting of Care
General Hospitals (646)
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.
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.
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.
HRSA patient safety and pharmacy collaborative is off to a good start.
Drug Formulary Review. April 1, 2009.
Hospital Engagement Network 2.0.
Department of Health and Human Services, Centers for Medicare & Medicaid Services. February 11, 2015. Solicitation No. RFP-CMS-APP150491-2014.
Hospital patient safety grades may misrepresent hospital performance.
Hwang W, Derk J, LaClair M, Paz H. J Hosp Med. 2014;9:111-115.
Hospital Reporting Program.
Portland, OR: Oregon Patient Safety Commission.
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.
African Partnerships for Patient Safety.
Geneva, Switzerland: WHO Patient Safety, World Health Organization.
BOOSTing Care Transitions Resource Room.
Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.
Tennessee Center for Patient Safety.
Learning accountability for patient outcomes.
Pronovost PJ. JAMA. 2010;304:204-205.
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
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.
Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.
Clarke D, Werestiuk K, Schoffner A, et al. J Nurs Manag. 2012;20:592-598.
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.
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.
Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.
O'Leary KJ, Sehgal NL, Terrell G, Williams MV; High Performance Teams and the Hospital of the Future Project Team. J Hosp Med. 2012;7:48-54.
The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.
Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.
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