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PATIENT SAFETY PRIMERS
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Device-related Complications (166)
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STUDY
Interruption handling strategies during paediatric medication administration.
Colligan L, Bass EJ. BMJ Qual Saf. 2012;21:912-917.
NEWSPAPER/MAGAZINE ARTICLE
Parents asking hospital for answers in death of infant.
News 3 Las Vegas (KVBC/DT). December 7, 2006.
REVIEW
The high-reliability pediatric intensive care unit.
Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.
COMMENTARY
Quality: performance improvement, teamwork, information technology and protocols.
Coleman NE, Pon S. Crit Care Clin. 2013;29:129-151.
COMMENTARY
Language Barrier
Flores G. AHRQ WebM&M [serial online]. April 2006.
STUDY
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.
NEWSPAPER/MAGAZINE ARTICLE
Perfect is possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
STUDY
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. 2012 Oct 31; [Epub ahead of print].
COMMENTARY
Improving safety throughout the medication use process in a neonatal intensive care unit.
Asdigha MN. Hosp Pharm. 2006;41:1067-1075.
COMMENTARY
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2005;40:844-847.
COMMENTARY
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
MULTI-USE WEBSITE
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2011.
STUDY
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.
STUDY
Patient misidentification in the neonatal intensive care unit: quantification of risk.
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
STUDY
Major congenital malformations after first-trimester exposure to ACE inhibitors.
Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. N Engl J Med. 2006;354:2443-2451.
NEWSPAPER/MAGAZINE ARTICLE
The best medical care in the U.S.
Arnst C. Business Week. July 17, 2006.
COMMENTARY
Unexplained Apnea under Anesthesia.
Barach P. AHRQ WebM&M [serial online]. February 2003.
STUDY
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
AUDIOVISUAL
Eye to eye: Donald Berwick.
"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.
COMMENTARY
Computerization can create safety hazards: a bar-coding near miss.
McDonald CJ. Ann Intern Med. 2006;144:510-516.
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