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 (318)
Clinical Guideline (1)
Journal Article (373)
Newspaper/Magazine Article (21)
Press Release/Announcement (4)
Special or Theme Issue (4)
Epidemiology of Errors and Adverse Events (155)
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 (57)
Health Care Providers (281)
Health Care Executives and Administrators (339)
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.
Quality: performance improvement, teamwork, information technology and protocols.
Coleman NE, Pon S. Crit Care Clin. 2013;29:129-151.
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.
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.
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.
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.
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.
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.
Improving safety throughout the medication use process in a neonatal intensive care unit.
Asdigha MN. Hosp Pharm. 2006;41:1067-1075.
Perfect is possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
Patient misidentification in the neonatal intensive care unit: quantification of risk.
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
Medical Mistakes: Dr. Oz Talks to Actor Dennis Quaid.
The Oprah Winfrey Show. March 10, 2009.
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.
Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.
Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.
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.
Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.
Larson EL, Cimiotti J, Haas J, et al. Arch Pediatr Adolesc Med. 2005;159:377-383.
Where’s the Feeding Tube?
Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.
Double Dosing, by the Rules
Cohen H. AHRQ WebM&M [serial online]. February/March 2009.
Infants at risk: when nurse fatigue jeopardizes quality care.
Dean GE, Scott LD, Rogers AE. Adv Neonatal Care. 2006;6:120-126.
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