U.S. Department of Health & Human Services
Intensive Care Units
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (67)
Diagnostic Errors (15)
Identification Errors (4)
Discontinuities, Gaps, and Hand-Off Problems (56)
Fatigue and Sleep Deprivation (13)
Medication Safety (131)
Medical Complications (99)
Nonsurgical Procedural Complications (9)
Surgical Complications (17)
Transfusion Complications (1)
Psychological and Social Complications (8)
Australia and New Zealand (12)
Central and South America (5)
North America (319)
Clinical Guideline (1)
Journal Article (374)
Newspaper/Magazine Article (21)
Press Release/Announcement (4)
Special or Theme Issue (4)
Epidemiology of Errors and Adverse Events (156)
Active Errors (78)
Latent Errors (40)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (99)
Legal and Policy Approaches (18)
Error Reporting and Analysis (107)
Communication Improvement (81)
Human Factors Engineering (86)
Specialization of Care (40)
Logistical Approaches (36)
Culture of Safety (59)
Technologic Approaches (61)
Education and Training (58)
Health Care Providers (281)
Health Care Executives and Administrators (340)
Non-Health Care Professionals (120)
Setting of Care
Intensive Care Units
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Dennis Quaid's Quest.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
The high-reliability pediatric intensive care unit.
Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.
Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.
Chandonnet CJ, Kahlon PS, Rachh P, et al. Pediatrics. 2013;131:e1961-e1969.
Perfect is possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
Implementation of the Josie King Care Journal in a pediatric intensive care unit: a quality improvement project.
Turner K, Frush K, Hueckel R, Relf MV, Thornlow D, Champagne MT. J Nurs Care Qual. 2013;28:257-264.
Quality: performance improvement, teamwork, information technology and protocols.
Coleman NE, Pon S. Crit Care Clin. 2013;29:129-151.
Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.
Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014;165:1245-1251.
Medical Mistakes: Dr. Oz Talks to Actor Dennis Quaid.
The Oprah Winfrey Show. March 10, 2009.
Improving safety throughout the medication use process in a neonatal intensive care unit.
Asdigha MN. Hosp Pharm. 2006;41:1067-1075.
Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.
Wetzel EA, Lang TR, Pendergrass TL, Taylor RG, Geis GL. Jt Comm J Qual Patient Saf. 2013;39:268-273.
Transitioning Newborns From NICU to Home: A Resource Toolkit.
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.
Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.
Patient misidentification in the neonatal intensive care unit: quantification of risk.
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
A case of the birth and death of a high reliability healthcare organisation.
Roberts KH, Madsen P, Desai V, Van Stralen D. Qual Saf Health Care. 2005;14:216-220.
Where’s the Feeding Tube?
Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.
Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.
Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Pediatrics. 2006;118:290-295.
The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit.
Cifra CL, Jones KL, Ascenzi J, et al. BMJ Qual Saf. 2014;23:930-938.
Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital.
Bonafide CP, Lin R, Zander M, et al. J Hosp Med. 2015;10:345-351.
Baby's death spotlights safety risks linked to computerized systems.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
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