U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (34)
Diagnostic Errors (2)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (87)
Fatigue and Sleep Deprivation (28)
Medication Safety (267)
Medical Complications (85)
Nonsurgical Procedural Complications (16)
Surgical Complications (58)
Transfusion Complications (1)
Psychological and Social Complications (44)
Australia and New Zealand (39)
Central and South America (2)
North America (626)
Journal Article (700)
Newspaper/Magazine Article (38)
Press Release/Announcement (1)
Special or Theme Issue (20)
Web Resource (4)
Epidemiology of Errors and Adverse Events (149)
Active Errors (129)
Latent Errors (88)
Near Miss (25)
Approach to Improving Safety
Quality Improvement Strategies (133)
Legal and Policy Approaches (23)
Error Reporting and Analysis (160)
Communication Improvement (165)
Human Factors Engineering (113)
Specialization of Care (40)
Logistical Approaches (120)
Culture of Safety (126)
Technologic Approaches (82)
Education and Training (165)
Allied Health Services (1)
Setting of Care
Psychiatric Facilities (8)
Residential Facilities (23)
Ambulatory Care (27)
Outpatient Surgery (2)
Patient Transport (3)
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SPECIAL OR THEME ISSUE
CMS 30-minute rule for drug administration needs revision.
ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.
Association of interruptions with an increased risk and severity of medication administration errors.
Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.
Implementing a safe and reliable process for medication administration.
Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.
Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.
Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.
Design for reliability: barcoded medication administration.
Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.
Medication safety initiative in reducing medication errors.
Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.
Nursing care quality and adverse events in US hospitals.
Lucero RJ, Lake ET, Aiken LH. J Clin Nurs. 2010;19:2185-2195.
Medication Administration Time Study (MATS): nursing staff performance of medication administration.
Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.
The application of Aronson's taxonomy to medication errors in nursing.
Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.
Work interruptions and their contribution to medication administration errors: an evidence review.
Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.
Guidelines for timely medication administration: response to the CMS "30-minute rule."
ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.
Adverse drug events in hospitalized cardiac patients.
Fanikos J, Cina JL, Baroletti S, Fiumara K, Matta L, Goldhaber SZ. Am J Cardiol. 2007;100:1465-1469.
Fall prevention in hospitals: an integrative review.
Spoelstra SL, Given BA, Given CW. Clin Nurs Res. 2012;21:92-112.
Effects of technological interventions on the safety of a medication-use system.
Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].
Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.
Taylor JA, Dominici F, Agnew J, Gerwin D, Morlock L, Miller MR. BMJ Qual Saf. 2012;21:101-111.
Going blank: factors contributing to interruptions to nurses' work and related outcomes.
Hall LM, Ferguson-Paré M, Peter E, et al. J Nurs Manag. 2010;18:1040-1047.
Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
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