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.
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.
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.
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.
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.
Shojania KG. AHRQ WebM&M [serial online]. February 2003.
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.
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.
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.
Effects of technological interventions on the safety of a medication-use system.
Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.
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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