U.S. Department of Health & Human Services
Quality and Safety Professionals
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (132)
Diagnostic Errors (160)
Identification Errors (93)
Discontinuities, Gaps, and Hand-Off Problems (331)
Fatigue and Sleep Deprivation (59)
Medication Safety (879)
Medical Complications (338)
Nonsurgical Procedural Complications (87)
Surgical Complications (397)
Transfusion Complications (15)
Psychological and Social Complications (86)
Australia and New Zealand (102)
Central and South America (7)
North America (2258)
Clinical Guideline (3)
Journal Article (2442)
Newspaper/Magazine Article (162)
Press Release/Announcement (14)
Special or Theme Issue (34)
Web Resource (54)
Epidemiology of Errors and Adverse Events (847)
Active Errors (643)
Latent Errors (281)
Near Miss (61)
Approach to Improving Safety
Quality Improvement Strategies (702)
Legal and Policy Approaches (137)
Error Reporting and Analysis (916)
Communication Improvement (622)
Human Factors Engineering (425)
Specialization of Care (189)
Logistical Approaches (187)
Culture of Safety (314)
Technologic Approaches (491)
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Quality and Safety Professionals
Setting of Care
Psychiatric Facilities (8)
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Ambulatory Care (241)
Outpatient Surgery (26)
Patient Transport (24)
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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.
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.
Achievements in eliminating healthcare-associated infections awards.
Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.
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.
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.
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.
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.
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.
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.
Supratherapeutic dosing of acetaminophen among hospitalized patients.
Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.
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.
Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.
Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.
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