U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Safety and Medical Education
Device-related Complications (153)
Diagnostic Errors (122)
Identification Errors (69)
Discontinuities, Gaps, and Hand-Off Problems (453)
Fatigue and Sleep Deprivation (90)
Medication Safety (795)
Medical Complications (483)
Nonsurgical Procedural Complications (55)
Surgical Complications (299)
Transfusion Complications (20)
Psychological and Social Complications (151)
Australia and New Zealand (128)
Central and South America (5)
North America (2569)
Clinical Guideline (2)
Journal Article (2450)
Newspaper/Magazine Article (404)
Press Release/Announcement (13)
Special or Theme Issue (53)
Web Resource (91)
Epidemiology of Errors and Adverse Events (937)
Active Errors (598)
Latent Errors (460)
Near Miss (54)
Approach to Improving Safety
Quality Improvement Strategies (853)
Legal and Policy Approaches (376)
Error Reporting and Analysis (1069)
Communication Improvement (807)
Human Factors Engineering (392)
Specialization of Care (262)
Logistical Approaches (241)
Culture of Safety (509)
Technologic Approaches (501)
Education and Training (663)
Allied Health Services (5)
Health Care Providers (2135)
Health Care Executives and Administrators (2862)
Non-Health Care Professionals (1514)
Setting of Care
General Hospitals (645)
Children’s Hospitals (79)
Specialty Hospitals (42)
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A new frontier in patient safety.
McCannon J, Berwick DM. JAMA
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.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2014.
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.
BOOSTing Care Transitions Resource Room.
Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.
Tennessee Center for Patient Safety.
African Partnerships for Patient Safety.
Geneva, Switzerland: WHO Patient Safety, World Health Organization.
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.
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
HealthGrades Sixth Annual Patient Safety in American Hospitals Study.
Golden, CO: HealthGrades, Inc.; April 2009.
Centers for Medicare & Medicaid Services.
Systematic review of the application of the plan-do-study-act method to improve quality in healthcare.
Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. BMJ Qual Saf. 2014;23:290-298.
Duty hour reform in a shifting medical landscape.
Jena AB, Prasad V. J Gen Intern Med. 2013;28:1238-1240.
Assessing and improving quality and safety.
Zeis M. HealthLeaders Media. July/August 2013;16:26-28.
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.
Eliminating CLABSI: A National Patient Safety Imperative.
Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.
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