U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Wrong Patient (42)
Wrong-Site Surgery (36)
Australia and New Zealand (3)
North America (130)
Journal Article (119)
Newspaper/Magazine Article (21)
Special or Theme Issue (1)
Web Resource (5)
Epidemiology of Errors and Adverse Events (58)
Active Errors (74)
Latent Errors (23)
Near Miss (14)
Approach to Improving Safety
Quality Improvement Strategies (53)
Legal and Policy Approaches (12)
Error Reporting and Analysis (57)
Communication Improvement (53)
Human Factors Engineering (45)
Specialization of Care (2)
Logistical Approaches (22)
Culture of Safety (12)
Technologic Approaches (55)
Education and Training (25)
Health Care Providers (123)
Health Care Executives and Administrators (140)
Non-Health Care Professionals (53)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (2)
Ambulatory Care (15)
Outpatient Surgery (10)
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In Conversation with…Eric G. Poon, MD, MPH
AHRQ WebM&M [serial online]. September 2008.
Wrist tag 'offers drug warning.'
BBC News. August 9, 2005.
Standardising wristbands improves patient safety.
Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.
A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning.
ISMP Medication Safety Alert! Acute Care Edition. October 23, 2014;19:1-5.
Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.
Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.
Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).
Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.
Automated identification of extreme-risk events in clinical incident reports.
Ong MS, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:e110-e118.
The use of patient pictures and verification screens to reduce computerized provider order entry errors.
Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.
Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.
Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.
Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.
ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.
Matching identifiers in electronic health records: implications for duplicate records and patient safety.
McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.
Hall LW. AHRQ WebM&M [serial online]. October 2008.
Shojania KG. AHRQ WebM&M [serial online]. February 2003.
Computerization can create safety hazards: a bar-coding near miss.
McDonald CJ. Ann Intern Med. 2006;144:510-516.
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.
A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.
Francis DL, Prabhakar S, Sanderson SO. Am J Gastroenterol. 2009;104:972-975.
The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.
Zarbo RJ, Tuthill JM, D'Angelo R, et al. Am J Clin Pathol. 2009;131:468-477.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
Specimen labeling errors in surgical pathology: an 18-month experience.
Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.
Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.
McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.
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