U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (3)
Diagnostic Errors (1)
Identification Errors (3)
Discontinuities, Gaps, and Hand-Off Problems (8)
Medication Safety (33)
Medical Complications (11)
Surgical Complications (33)
Psychological and Social Complications (5)
Australia and New Zealand (3)
North America (64)
Clinical Guideline (1)
Journal Article (70)
Newspaper/Magazine Article (6)
Special or Theme Issue (3)
Web Resource (1)
Epidemiology of Errors and Adverse Events (22)
Active Errors (17)
Latent Errors (4)
Near Miss (4)
Approach to Improving Safety
Quality Improvement Strategies (19)
Legal and Policy Approaches (2)
Error Reporting and Analysis (14)
Communication Improvement (26)
Human Factors Engineering (15)
Logistical Approaches (11)
Culture of Safety (17)
Technologic Approaches (10)
Education and Training (15)
Health Care Providers (73)
Health Care Executives and Administrators (75)
Non-Health Care Professionals (29)
Setting of Care
Psychiatric Facilities (5)
Residential Facilities (1)
Ambulatory Care (1)
Outpatient Surgery (2)
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Prevalence of medication administration errors in two medical units with automated prescription and dispensing.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.
The incidence and nature of prescribing and medication administration errors in paediatric inpatients.
Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.
Prioritising the prevention of medication handling errors.
Bertsche T, Niemann D, Mayer Y, Ingram K, Hoppe-Tichy T, Haefeli WE. Pharm World Sci. 2008;30:907-915.
SPECIAL OR THEME ISSUE
CMS 30-minute rule for drug administration needs revision.
ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.
The Result Stopped Here.
Astion M. AHRQ WebM&M [serial online]. June 2004.
Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.
Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.
Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.
Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.
An observational study of medication administration errors in old-age psychiatric inpatients.
Haw C, Stubbs J, Dickens G. Int J Qual Health Care. 2007;19:210-216.
Nurses' satisfaction with medication administration point-of-care technology.
Hurley AC, Bane A, Fotakis S, et al. J Nurs Adm. 2007;37:343-349.
Impact of barcode medication administration technology on how nurses spend their time providing patient care.
Poon EG, Keohane CA, Bane A, et al. J Nurs Adm. 2008;38:541-549.
Reducing interruptions to improve medication safety.
Freeman R, McKee S, Lee-Lehner B, Pesenecker J. J Nurs Care Qual. 2013;28:176-185.
Nurses' clinical reasoning: processes and practices of medication safety.
Dickson GL, Flynn L. Qual Health Res. 2012;22:3-16.
SPECIAL OR THEME ISSUE
SafetyNet: Lessons Learned from Close Calls in the OR.
AORN J. 2006;84(suppl 1):S1-S63.
Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.
Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.
Priority patient safety issues identified by perioperative nurses.
Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.
Effects of learning climate and registered nurse staffing on medication errors.
Chang Y, Mark B. Nurs Res. 2011;60:32-39.
Interruptions and miscommunications in surgery: an observational study.
Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.
Communication elements supporting patient safety in psychiatric inpatient care.
Kanerva A, Kivinen T, Lammintakanen J. J Psychiatr Ment Health Nurs. 2015 Feb 16; [Epub ahead of print].
Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.
Wauben LS, Dekker-van Doorn CM, van Wijngaarden JD, et al. Int J Qual Health Care. 2011;23:159-166.
Can your nurses stop a surgeon?
Weinstock M. Hosp Health Netw. 2007;81:38-40, 42, 44-46.
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