U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (67)
Diagnostic Errors (36)
Identification Errors (26)
Discontinuities, Gaps, and Hand-Off Problems (277)
Fatigue and Sleep Deprivation (52)
Medication Safety (371)
Medical Complications (303)
Nonsurgical Procedural Complications (15)
Surgical Complications (81)
Transfusion Complications (10)
Psychological and Social Complications (87)
Australia and New Zealand (62)
Central and South America (2)
North America (1407)
Journal Article (1310)
Newspaper/Magazine Article (224)
Press Release/Announcement (5)
Special or Theme Issue (21)
Web Resource (46)
Epidemiology of Errors and Adverse Events (571)
Active Errors (280)
Latent Errors (265)
Near Miss (23)
Approach to Improving Safety
Quality Improvement Strategies (447)
Legal and Policy Approaches (195)
Error Reporting and Analysis (548)
Communication Improvement (429)
Human Factors Engineering (174)
Specialization of Care (129)
Logistical Approaches (133)
Culture of Safety (291)
Technologic Approaches (252)
Education and Training (308)
Health Care Providers (928)
Health Care Executives and Administrators (1541)
Non-Health Care Professionals (808)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (8)
Ambulatory Care (37)
Outpatient Surgery (4)
Patient Transport (5)
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Medication errors: when pharmacy is closed.
PA-PSRS Patient Saf Advis. March 2012;9:11-17.
Engaging patients in medication reconciliation via a patient portal following hospital discharge.
Heyworth L, Paquin AM, Clark J, et al. J Am Med Inform Assoc. 2014;21:e157-e162.
What happens to the medication regimens of older adults during and after an acute hospitalization?
Harris CM, Sridharan A, Landis R, Howell E, Wright S. J Patient Saf. 2013;9:150-153.
Medication errors occurring with the use of bar-code administration technology.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
Hospital-based medication reconciliation practices: a systematic review.
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.
Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.
Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.
Medication regimen complexity and hospital readmission for an adverse drug event.
Willson MN, Greer CL, Weeks DL. Ann Pharmacother. 2014;48:26-32.
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.
Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.
Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists.
Lee KP, Nishimura K, Ngu B, Tieu L, Auerbach AD. Ann Pharmacother. 2014;48:168-177.
Quality improvement through implementation of discharge order reconciliation.
Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.
Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
Improvement of medication event interventions through use of an electronic database.
Merandi J, Morvay S, Lewe D, et al. Am J Health Syst Pharm. 2013;70:1708-1714.
Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.
Reporting trends in a regional medication error data-sharing system.
Anderson JG, Ramanujam R, Hensel DJ, Sirio CA. Health Care Manag Sci. 2010;13:74-83.
Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.
Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.
Rural inpatient telepharmacy consultation demonstration for after-hours medication review.
Cole SL, Grubbs JH, Din C, Nesbitt TS. Telemed E Health. 2012;18:530-537.
The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.
Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. Jt Comm J Qual Patient Saf. 2006;32:299-308.
Overrides of medication-related clinical decision support alerts in outpatients.
Nanji KC, Slight SP, Seger DL, et al. J Am Med Inform Assoc. 2014;21:487-491.
MARQUIS Medication Reconciliation Resource Center.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). Philadelpha, PA: Society for Hospital Medicine.
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
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