U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (22)
Diagnostic Errors (2)
Identification Errors (6)
Discontinuities, Gaps, and Hand-Off Problems (24)
Fatigue and Sleep Deprivation (8)
Medication Safety (57)
Medical Complications (15)
Nonsurgical Procedural Complications (15)
Surgical Complications (151)
Transfusion Complications (1)
Psychological and Social Complications (10)
Australia and New Zealand (23)
North America (182)
Clinical Guideline (2)
Journal Article (238)
Newspaper/Magazine Article (24)
Press Release/Announcement (1)
Special or Theme Issue (8)
Web Resource (7)
Epidemiology of Errors and Adverse Events (72)
Active Errors (60)
Latent Errors (24)
Near Miss (5)
Approach to Improving Safety
Quality Improvement Strategies (64)
Legal and Policy Approaches (22)
Error Reporting and Analysis (67)
Communication Improvement (62)
Human Factors Engineering (75)
Specialization of Care (8)
Logistical Approaches (15)
Culture of Safety (24)
Technologic Approaches (30)
Education and Training (70)
Health Care Providers (233)
Health Care Executives and Administrators (199)
Non-Health Care Professionals (87)
Setting of Care
Ambulatory Care (12)
Outpatient Surgery (9)
Patient Transport (2)
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Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.
SPECIAL OR THEME ISSUE
Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.
Amer Surg. 2006;72:985-1149
National pediatric anesthesia safety quality improvement program in the United States.
Kurth CD, Tyler D, Heitmiller E, Tosone SR, Martin L, Deshpande JK. Anesth Analg. 2014;119:112-121.
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.
SPECIAL OR THEME ISSUE
Quality of Anesthesia Care.
Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.
The Wild West: Patient Safety in Office-Based Anesthesia
Kaushal R, Upadhyayula S, Gaba DM, Leape LL. AHRQ WebM&M [serial online]. May 2006.
Adverse event reporting: lessons learned from 4 years of Florida office data.
Coldiron B, Fisher AH, Adelman E, et al. Dermatol Surg. 2005;31(pt 1):1079-1092; discussion 1093.
Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.
Gordon NA, Koch ME. Arch Facial Plast Surg. 2006;8:47-53.
Trends influencing the cost of care and patient safety.
Clark R. Health Manage Tech. July 2006:18, 20-21.
Time of day effects on the incidence of anesthetic adverse events.
Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.
The perianesthesia nurse's role in the prevention of opioid-related sentinel events.
Pasero C. J Perianesth Nurs. 2013;28:31-37.
A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.
Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.
Sedation and patient safety.
Simmons D. Crit Care Nurs Clin North Am. 2005;17:279-285.
Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Administrative issues to ensure safe anesthesia care in the office-based setting.
Gaulton TG, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2013;26:692-697.
FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.
Barbeito A, Lau WT, Weitzel N, Abernathy JH III, Wahr J, Mark JB. Anesth Analg. 2014;119:777-783.
The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.
De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. Anesth Analg. 2013;116:892-897.
Office-based anesthesia: safety and outcomes.
Shapiro FE, Punwani N, Rosenberg NM, Valedon A, Twersky R, Urman RD. Anesth Analg. 2014;119:276-285.
Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration.
Caruso TJ, Marquez JL, Wu DS, et al. Jt Comm J Qual Patient Saf. 2015;41:35-42.
An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.
Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.
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