U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (40)
Diagnostic Errors (25)
Identification Errors (19)
Discontinuities, Gaps, and Hand-Off Problems (185)
Fatigue and Sleep Deprivation (10)
Medication Safety (292)
Medical Complications (158)
Nonsurgical Procedural Complications (8)
Surgical Complications (39)
Transfusion Complications (7)
Psychological and Social Complications (30)
Australia and New Zealand (34)
Central and South America (1)
North America (716)
Journal Article (648)
Newspaper/Magazine Article (90)
Press Release/Announcement (4)
Special or Theme Issue (13)
Web Resource (25)
Epidemiology of Errors and Adverse Events (262)
Active Errors (196)
Latent Errors (124)
Near Miss (14)
Approach to Improving Safety
Quality Improvement Strategies (253)
Legal and Policy Approaches (55)
Error Reporting and Analysis (205)
Communication Improvement (323)
Human Factors Engineering (101)
Specialization of Care (75)
Logistical Approaches (51)
Culture of Safety (131)
Technologic Approaches (171)
Education and Training (181)
Health Care Providers (740)
Health Care Executives and Administrators (777)
Non-Health Care Professionals (355)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (4)
Ambulatory Care (30)
Outpatient Surgery (2)
Patient Transport (3)
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Forster A. AHRQ WebM&M [serial online]. December 2004.
The Dropped Lung.
Heffner JE. AHRQ WebM&M [serial online]. May 2003.
Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.
Too Tight Control.
Rubin HR, Fajtova VT. AHRQ WebM&M [serial online]. May 2004.
Adams JG. AHRQ WebM&M [serial online]. June 2003.
Impact of a standard medication chart on prescribing errors: a before-and-after audit.
Coombes ID, Stowasser DA, Reid C, Mitchell CA. Qual Saf Health Care. 2009;18:478-485.
Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
Listen to the Family.
Campbell D Jr. AHRQ WebM&M [serial online]. June 2004.
Crushing Chest Pain: A Missed Opportunity.
Graber M. AHRQ WebM&M [serial online]. January 2004.
Code Status Confusion.
Lo B, Tulsky JA. AHRQ WebM&M [serial online]. July 2003.
Interventions to improve team effectiveness: a systematic review.
Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP. Health Policy. 2010;94:183-195.
Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.
Delay in Initiating Antibiotics Leads to Fatal Error.
Bellini LM. AHRQ WebM&M [serial online]. February 2004.
A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience.
Sehgal NL, Fox M, Vidyarthi AR, et al; TOPS Project. J Gen Intern Med. 2008;23:2053-2057.
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.
Collins TR. The Hospitalist. July 2011.
Check the Bags.
Caldwell M, Dracup KA. AHRQ WebM&M [serial online]. September 2003.
TeamSTEPPS Master Training Course.
Johns Hopkins Armstrong Institute for Patient Safety and Quality. September 2-3, 2015; Constellation Energy Building, Baltimore, MD.
Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.
Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.
Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review.
Rabøl LI, Østergaard D, Mogensen T. Qual Saf Health Care. 2010;19:e27.
Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study.
Westbrook JI, Reckmann M, Li L, et al. PLoS Med. 2012;9:e1001164.
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