U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
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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.
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.
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.
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.
Computerization can create safety hazards: a bar-coding near miss.
McDonald CJ. Ann Intern Med. 2006;144:510-516.
Hall LW. AHRQ WebM&M [serial online]. October 2008.
Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.
Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.
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.
Shojania KG. AHRQ WebM&M [serial online]. February 2003.
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.
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.
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.
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.
Improving America's Hospitals: A Report on Quality and Safety.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
Specimen labeling errors in surgical pathology: an 18-month experience.
Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2014.
An observational study of how patients are identified before medication administrations in medical and surgical wards.
Härkänen M, Kervinen M, Ahonen J, Turunen H, Vehviläinen-Julkunen K. Nurs Health Sci. 2014 Jul 8; [Epub ahead of print].
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