U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (81)
Clinical Guideline (1)
Journal Article (59)
Newspaper/Magazine Article (22)
Web Resource (3)
Epidemiology of Errors and Adverse Events (32)
Active Errors (45)
Latent Errors (5)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (32)
Legal and Policy Approaches (14)
Error Reporting and Analysis (39)
Communication Improvement (45)
Human Factors Engineering (25)
Specialization of Care (1)
Logistical Approaches (3)
Culture of Safety (10)
Technologic Approaches (5)
Education and Training (16)
Health Care Providers (65)
Health Care Executives and Administrators (69)
Non-Health Care Professionals (18)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (8)
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Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
A 62-year-old woman with skin cancer who experienced wrong-site surgery.
Gallagher TH. JAMA. 2009;302:669-677.
Joint Commission Center for Transforming Healthcare.
The Joint Commission.
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
Incidence, patterns, and prevention of wrong-site surgery.
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
Wrong-side thoracentesis: lessons learned from root cause analysis.
Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-779.
Surgical never events in the United States.
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
Incorrect surgical procedures within and outside of the operating room: a follow-up report.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.
Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
Washington Patient Safety Coalition.
Foundation for Health Care Quality, 705 2nd Avenue, Suite 703, Seattle, WA 98104.
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Improving America's Hospitals: A Report on Quality and Safety.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Hospitalized patients' attitudes about and participation in error prevention.
Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. J Gen Intern Med. 2006;21:367-370.
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