U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (3)
Diagnostic Errors (8)
Identification Errors (1)
Discontinuities, Gaps, and Hand-Off Problems (9)
Fatigue and Sleep Deprivation (1)
Medication Safety (11)
Medical Complications (12)
Nonsurgical Procedural Complications (2)
Surgical Complications (3)
Transfusion Complications (1)
Psychological and Social Complications (2)
Australia and New Zealand (4)
North America (52)
Journal Article (57)
Newspaper/Magazine Article (6)
Web Resource (1)
Epidemiology of Errors and Adverse Events (21)
Active Errors (15)
Latent Errors (6)
Approach to Improving Safety
Quality Improvement Strategies (13)
Legal and Policy Approaches (3)
Error Reporting and Analysis (17)
Communication Improvement (19)
Human Factors Engineering (6)
Specialization of Care (20)
Logistical Approaches (7)
Culture of Safety (4)
Technologic Approaches (9)
Education and Training (12)
Health Care Providers (52)
Health Care Executives and Administrators (47)
Non-Health Care Professionals (14)
Setting of Care
Ambulatory Care (2)
Patient Transport (4)
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A review of current and emerging approaches to address failure-to-rescue.
Taenzer AH, Pyke JB, McGrath SP. Anesthesiology. 2011;115:421-431.
Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2015;24:203-211.
Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.
Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-346.
Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.
Ranji SR, Auerbach AD, Hurd CJ, O'Rourke K, Shojania KG. J Hosp Med. 2007;2:422-432.
Using an automated risk assessment report to identify patients at risk for clinical deterioration.
Whittington J, White R, Haig KM, Slock M. Jt Comm J Qual Patient Saf. 2007;33:569-574.
Maryland Patient Safety Center Emergency Department Collaborative.
Maryland Patient Safety Center.
Experience with family activation of rapid response teams.
Bogert S, Ferrell C, Rutledge DN. Medsurg Nurs. 2010;19:215-222.
Implementation of Condition Help: family teaching and evaluation of family understanding.
Hueckel RM, Mericle JM, Frush K, Martin PL, Champagne MT. J Nurs Care Qual. 2012;27:176-181.
A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.
Hanson CC, Randolph GD, Erickson JA, et al. Qual Saf Health Care. 2009;18:500-504.
Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension.
Quach JL, Downey AW, Haase M, et al. J Crit Care. 2008;23:325-331.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:696–698.
A survey of nurses' beliefs about the medical emergency team system in a Canadian tertiary hospital.
Bagshaw SM, Mondor EE, Scouten C, et al; Capital Health Medical Emergency Team Investigators. Am J Crit Care. 2010;19:74-83.
Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.
Santamaria J, Tobin A, Holmes J. Crit Care Med. 2010;38:445-450.
Ethical and practical aspects of disclosing adverse events in the emergency department.
Stokes SL, Wu AW, Pronovost PJ. Emerg Med Clin North Am. 2006;24:703-714.
Infection prevention in the emergency department.
Liang SY, Theodoro DL, Schuur JD, Marschall J. Ann Emerg Med. 2014;64:299-313.
Detection of missed injuries in a pediatric trauma center with the addition of acute care pediatric nurse practitioners.
Resler J, Hackworth J, Mayo E, Rouse TM. J Trauma Nurs. 2014;21:272-275.
The medical emergency team as a safety net.
Buttfield MA, Amos JD, Hillman KM. Jt Comm J Qual Patient Saf. 2006;32:641-645.
Medical emergency team calls: the need to communicate a resuscitation plan.
MacPartlin M, Hillman KM. Jt Comm J Qual Patient Saf. 2007;33:54-56.
Early prognostic value of the medical emergency team calling criteria in patients admitted to intensive care from the emergency department.
Etter R, Ludwig R, Lersch F, Takala J, Merz TM. Crit Care Med. 2008;36:775-781.
Single-parameter early warning criteria to predict life-threatening adverse events.
Rothschild JM, Gandara E, Woolf S, Williams DH, Bates DW. J Patient Saf. 2010;6:97-101.
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