U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (80)
Clinical Guideline (1)
Journal Article (58)
Newspaper/Magazine Article (20)
Web Resource (2)
Epidemiology of Errors and Adverse Events (31)
Active Errors (45)
Latent Errors (5)
Near Miss (6)
Approach to Improving Safety
Quality Improvement Strategies (29)
Legal and Policy Approaches (13)
Error Reporting and Analysis (39)
Communication Improvement (43)
Human Factors Engineering (24)
Specialization of Care (1)
Logistical Approaches (2)
Culture of Safety (8)
Technologic Approaches (3)
Education and Training (14)
Health Care Providers (63)
Health Care Executives and Administrators (66)
Non-Health Care Professionals (17)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (1)
Ambulatory Care (5)
Outpatient Surgery (8)
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Surgical site verification: A through Z.
Dunn D. J Perianesth Nurs. 2006;21:317-328.
'Wrong site' surgeries on the rise.
Davis R. USA Today. April 17, 2006.
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.
The Joint Commission.
Incidence, patterns, and prevention of wrong-site surgery.
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.
Avoiding wrong site surgery: a systematic review.
DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.
Wrong body part, wrong patient surgeries continue despite new procedures.
Rojas-Burke J. The Oregonian. May 25, 2011.
'Wrong-site' surgical mistakes are rare, preventable.
Stein L. St. Petersburg Times. June 21, 2010.
Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Operating room briefings and wrong-site surgery.
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
Time out: an analysis.
Dillon KA. AORN J. 2008;88:437-442.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
Getting surgery right.
Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.
Preventing wrong-site surgery in Minnesota: a 5-year journey.
Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.
Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
Spinal surgery and patient safety: a systems approach.
Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.
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