U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (13)
Central and South America (4)
North America (296)
Journal Article (294)
Newspaper/Magazine Article (55)
Press Release/Announcement (12)
Special or Theme Issue (3)
Epidemiology of Errors and Adverse Events (124)
Active Errors (166)
Latent Errors (44)
Near Miss (13)
Approach to Improving Safety
Quality Improvement Strategies (98)
Legal and Policy Approaches (26)
Error Reporting and Analysis (98)
Communication Improvement (42)
Human Factors Engineering (103)
Specialization of Care (18)
Logistical Approaches (27)
Culture of Safety (22)
Technologic Approaches (103)
Education and Training (85)
Allied Health Services (2)
Health Care Providers (329)
Health Care Executives and Administrators (309)
Non-Health Care Professionals (122)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (13)
Ambulatory Care (28)
Outpatient Surgery (3)
Patient Transport (4)
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ISMP medication error report analysis.
Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.
Epidural-IV route mix-ups: reducing the risk of deadly errors.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
Medication safety initiative in reducing medication errors.
Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.
Bar code technology and medication administration error.
Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.
ISMP medication error report analysis.
Cohen MR. Hosp Pharm. 2008;43:696–698.
Effect of bar-code technology on the safety of medication administration.
Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.
Guidelines for Adult IV Push Medications.
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
Bar-code verification: reducing but not eliminating medication errors.
Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.
A clinical reminder about the safe use of insulin vials.
ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.
Administering a saline flush "site unseen" can lead to a wrong route error.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Medication-related patient safety incidents in critical care: a review of reports to the UK National Patient Safety Agency.
Thomas AN, Panchagnula U. Anaesthesia. 2008;63:726-733.
Design for reliability: barcoded medication administration.
Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.
Anticoagulation-associated adverse drug events.
Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.
SPECIAL OR THEME ISSUE
Special Issue: Patient Safety.
2014–2015 Targeted Medication Safety Best Practices for Hospitals.
Horsham, PA: Institute for Safe Medication Practices.
ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
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.
Bar-Coded Medication Administration (BCMA).
Decisionmaker Brief. AHRQ Publication No: 08-0085, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.
Shaping systems for better behavioral choices: lessons learned from a fatal medication error.
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Implementing a safe and reliable process for medication administration.
Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.
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