U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (67)
Diagnostic Errors (36)
Identification Errors (27)
Discontinuities, Gaps, and Hand-Off Problems (276)
Fatigue and Sleep Deprivation (52)
Medication Safety (373)
Medical Complications (303)
Nonsurgical Procedural Complications (15)
Surgical Complications (82)
Transfusion Complications (10)
Psychological and Social Complications (88)
Australia and New Zealand (62)
Central and South America (2)
North America (1407)
Journal Article (1312)
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 (281)
Latent Errors (266)
Near Miss (23)
Approach to Improving Safety
Quality Improvement Strategies (448)
Legal and Policy Approaches (196)
Error Reporting and Analysis (548)
Communication Improvement (430)
Human Factors Engineering (174)
Specialization of Care (129)
Logistical Approaches (132)
Culture of Safety (293)
Technologic Approaches (254)
Education and Training (308)
Health Care Providers (929)
Health Care Executives and Administrators (1542)
Non-Health Care Professionals (809)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (8)
Ambulatory Care (37)
Outpatient Surgery (4)
Patient Transport (4)
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Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
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.
Perfect is possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
Achievements in eliminating healthcare-associated infections awards.
Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.
Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Am J Infect Control. 2014;42:106-110.
A multidisciplinary approach to reduce central line–associated bloodstream infections.
McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.
Balancing "no blame" with accountability in patient safety.
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.
Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.
On the CUSP: Stop HAI.
Health Research & Educational Trust, MHA Keystone Center.
Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.
Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.
Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.
McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.
Using the opportunity estimator tool to improve engagement in a quality and safety intervention.
Duval-Arnould J, Mathews SC, Weeks K, et al. Jt Comm J Qual Patient Saf. 2012;38:41-47.
Battling hospital-acquired infections.
Gross T. "Fresh Air." National Public Radio. January 9, 2008.
Utilizing improvement science methods to improve physician compliance with proper hand hygiene.
White CM, Statile AM, Conway PH, et al. Pediatrics. 2012;129:e1042-e1050.
Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study.
Jessee MA, Mion LC. Am J Infect Control. 2013;41:965-970.
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.
The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care.
Dai H, Milkman KL, Hofmann DA, Staats BR. J Appl Psychol. 2014 Nov 3; [Epub ahead of print].
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