U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (16)
Identification Errors (2)
Discontinuities, Gaps, and Hand-Off Problems (33)
Medication Safety (323)
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Nonsurgical Procedural Complications (1)
Surgical Complications (4)
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Clinical Guideline (1)
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Epidemiology of Errors and Adverse Events (124)
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Approach to Improving Safety
Quality Improvement Strategies (60)
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Error Reporting and Analysis (60)
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Human Factors Engineering (67)
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Health Care Providers (260)
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Non-Health Care Professionals (98)
Setting of Care
Psychiatric Facilities (1)
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Wears RL. AHRQ WebM&M [serial online]. September 2004.
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.
40 of K.
Lesar TS. AHRQ WebM&M [serial online]. November 2003.
Using CPOE to improve communication, safety, and policy compliance when ordering pediatric chemotherapy.
Crossno CL, Cartwright JA, Hargrove FR. Hosp Pharm. 2007;42:368–373.
Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
Dose of technology helps Shands at UF avoid drug errors.
Chun D. Gainsville Sun. August 21, 2006.
Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists.
Wakefield DS, Ward MM, Loes JL, O'Brien J, Sperry L. Am J Health Syst Pharm. 2010;67:2052-2057.
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.
Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.
Heparin overdose in three infants revisits hospital error issues.
Phend C. MedPage Today. November 26, 2007.
Mixed results in the safety performance of computerized physician order entry.
Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.
Collins TR. The Hospitalist. July 2011.
Back to Basics
Hellman R. AHRQ WebM&M [serial online]. March 2007.
Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.
Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Drug Saf. 2010;33:1027-1044.
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.
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.
Anticoagulant safety practices call for pharmacist supervision.
Scott A. Drug Topics (Health-System Edition). November 10, 2008.
Impact of electronic prescribing in a hospital setting: a process-focused evaluation.
Cunningham TR, Geller ES, Clarke SW. Int J Med Inform. 2008;77:546-554.
Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.
Hilmas E, Peoples JD. JPEN J Parenter Enteral Nutr. 2012;36(suppl 2):32S-35S.
A review of verbal order policies in acute care hospitals.
Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.
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