U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (14)
Diagnostic Errors (25)
Identification Errors (6)
Discontinuities, Gaps, and Hand-Off Problems (36)
Fatigue and Sleep Deprivation (30)
Medication Safety (95)
Medical Complications (82)
Nonsurgical Procedural Complications (5)
Surgical Complications (55)
Transfusion Complications (2)
Psychological and Social Complications (15)
Australia and New Zealand (16)
Central and South America (3)
North America (532)
Journal Article (344)
Newspaper/Magazine Article (71)
Press Release/Announcement (5)
Special or Theme Issue (14)
Web Resource (32)
Epidemiology of Errors and Adverse Events (139)
Active Errors (49)
Latent Errors (72)
Near Miss (7)
Approach to Improving Safety
Quality Improvement Strategies (181)
Legal and Policy Approaches (321)
Error Reporting and Analysis (305)
Communication Improvement (74)
Human Factors Engineering (31)
Specialization of Care (11)
Logistical Approaches (48)
Culture of Safety (93)
Technologic Approaches (85)
Education and Training (96)
Allied Health Services (2)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (11)
Ambulatory Care (57)
Outpatient Surgery (13)
Patient Transport (1)
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A new frontier in patient safety.
McCannon J, Berwick DM. JAMA
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2014.
Adverse Events in Hospitals: Overview of Key Issues.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.
Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.
HRSA patient safety and pharmacy collaborative is off to a good start.
Drug Formulary Review. April 1, 2009.
Hospital Engagement Network 2.0.
Department of Health and Human Services, Centers for Medicare & Medicaid Services. February 11, 2015. Solicitation No. RFP-CMS-APP150491-2014.
Hospital patient safety grades may misrepresent hospital performance.
Hwang W, Derk J, LaClair M, Paz H. J Hosp Med. 2014;9:111-115.
The partnership with patients: a call to action for leaders.
Denham CR. J Patient Saf. 2011;7:113-121.
Hospital Reporting Program.
Portland, OR: Oregon Patient Safety Commission.
National trends in patient safety for four common conditions, 2005–2011.
Wang Y, Eldridge N. Metersky ML, et al. N Engl J Med. 2014;370:341-351.
African Partnerships for Patient Safety.
Geneva, Switzerland: WHO Patient Safety, World Health Organization.
Tennessee Center for Patient Safety.
Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice.
Cortes-Penfield N. Am J Public Health. 2014;104:2060-2065.
How much diagnostic safety can we afford, and how should we decide? A health economics perspective.
Newman-Toker DE, McDonald KM, Meltzer DO. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.
Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.
Advancing Patient Safety: A Decade of Evidence, Design, and Implementation.
Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Oakbrook Terrace, IL: The Joint Commission; January 2010.
Safety First: Top of Your Board's Agenda: 100 Day Challenge Survey Report.
The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.
Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals.
Austin JM, D'Andrea G, Birkmeyer JD, et al. J Patient Saf. 2014;10:64-71.
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
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