U.S. Department of Health & Human Services
Health Care Providers
PATIENT SAFETY PRIMERS
Improving Communication Between Clinicians
2014 ANNUAL PERSPECTIVES
Device-related Complications (186)
Diagnostic Errors (274)
Identification Errors (109)
Discontinuities, Gaps, and Hand-Off Problems (543)
Fatigue and Sleep Deprivation (115)
Medication Safety (1395)
Medical Complications (508)
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Surgical Complications (484)
Transfusion Complications (18)
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Australia and New Zealand (112)
Central and South America (10)
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Clinical Guideline (9)
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Special or Theme Issue (76)
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Epidemiology of Errors and Adverse Events (1150)
Active Errors (928)
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Approach to Improving Safety
Quality Improvement Strategies (1053)
Legal and Policy Approaches (326)
Error Reporting and Analysis (1261)
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On the CUSP: Stop HAI.
Health Research & Educational Trust, MHA Keystone Center.
Tubing Misconnections Self Assessment for Healthcare Facilities.
Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
Fakih MG, George C, Edson BS, Goeschel CA, Saint S. Infect Control Hosp Epidemiol. 2013;34:1048-1054.
Achievements in eliminating healthcare-associated infections awards.
Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.
Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Infusing fun into quality and safety initiatives.
Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.
Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
Parent willingness to remind health care workers to perform hand hygiene.
Buser GL, Fisher BT, Shea JA, Coffin SE. Am J Infect Control. 2013;41:492-496.
Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.
Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).
Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.
Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Am J Infect Control. 2014;42:106-110.
Health Care–Associated Infections (HAI) Portal.
The Joint Commission.
Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.
Balancing "no blame" with accountability in patient safety.
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
A multidisciplinary approach to reduce central line–associated bloodstream infections.
McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.
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