U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (1)
North America (50)
Journal Article (48)
Newspaper/Magazine Article (8)
Press Release/Announcement (2)
Epidemiology of Errors and Adverse Events (17)
Active Errors (14)
Latent Errors (6)
Near Miss (1)
Approach to Improving Safety
Quality Improvement Strategies (13)
Legal and Policy Approaches (1)
Error Reporting and Analysis (20)
Communication Improvement (5)
Human Factors Engineering (43)
Specialization of Care (3)
Logistical Approaches (1)
Culture of Safety (2)
Technologic Approaches (23)
Education and Training (9)
Health Care Providers (35)
Health Care Executives and Administrators (53)
Non-Health Care Professionals (28)
Setting of Care
Ambulatory Care (1)
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Intravenous infusion safety technology: return on investment.
Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.
ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.
Tran M, Ciarkowski S, Wagner D, Stevenson JG. Jt Comm J Qual Patient Saf. 2012;38:112-119.
Misprogramming PCA concentration leads to dosing errors.
ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.
Smart pumps: advanced capabilities and continuous quality improvement.
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.
Smart pump custom concentrations without hard "low concentration" alerts.
ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.
Smart pumps: implications for nurse leaders.
Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
The rate and costs attributable to intravenous patient-controlled analgesia errors.
Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.
Are Two Insulin Pumps Better Than One?
Cook CB. AHRQ WebM&M [serial online]. January 2009.
Fluorouracil Incident Root Cause Analysis Report.
Toronto, ON, Canada: Institute for Safe Medication Practices Canada. April 30, 2007.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:960-964.
New technology, new errors: how to prime an upgrade of an insulin infusion pump.
Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.
Impact of a comprehensive safety initiative on patient-controlled analgesia errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group.
Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Diabetes Care. 2015;38:716-722.
Strategic work-arounds to accommodate new technology: the case of smart pumps in hospital care.
McAlearney AS, Vrontos J Jr, Schneider PJ, Curran CR, Czerwinski BS, Pedersen CA. J Patient Saf. 2007;3:75-81.
The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.
Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].
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