U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (67)
Diagnostic Errors (35)
Identification Errors (27)
Discontinuities, Gaps, and Hand-Off Problems (276)
Fatigue and Sleep Deprivation (51)
Medication Safety (369)
Medical Complications (302)
Nonsurgical Procedural Complications (15)
Surgical Complications (82)
Transfusion Complications (10)
Psychological and Social Complications (85)
Australia and New Zealand (62)
Central and South America (2)
North America (1395)
Journal Article (1299)
Newspaper/Magazine Article (223)
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Special or Theme Issue (21)
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Epidemiology of Errors and Adverse Events (556)
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Approach to Improving Safety
Quality Improvement Strategies (445)
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Error Reporting and Analysis (544)
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Human Factors Engineering (172)
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Setting of Care
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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.
Achievements in eliminating healthcare-associated infections awards.
Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.
New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).
Oakbrook Terrace, IL: Joint Commission; May 17, 2011.
Perfect is possible.
Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.
Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.
The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.
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.
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.
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.
Battling hospital-acquired infections.
Gross T. "Fresh Air." National Public Radio. January 9, 2008.
Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.
Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. J Acad Nutr Diet. 2012;112:1656-1661.
Rounding to influence.
Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.
Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.
Clare CA, Afzal O, Knapp K, Viola D. J Patient Saf. 2013;9:68-74.
Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.
Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.
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