U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Australia and New Zealand (3)
North America (84)
Clinical Guideline (2)
Journal Article (72)
Newspaper/Magazine Article (2)
Special or Theme Issue (4)
Web Resource (5)
Epidemiology of Errors and Adverse Events (34)
Active Errors (7)
Latent Errors (5)
Near Miss (2)
Approach to Improving Safety
Quality Improvement Strategies (34)
Legal and Policy Approaches (6)
Error Reporting and Analysis (33)
Communication Improvement (16)
Human Factors Engineering (16)
Specialization of Care (6)
Logistical Approaches (16)
Culture of Safety (15)
Technologic Approaches (8)
Education and Training (13)
Health Care Providers (70)
Health Care Executives and Administrators (89)
Non-Health Care Professionals (30)
Setting of Care
Psychiatric Facilities (3)
Residential Facilities (12)
Ambulatory Care (13)
Outpatient Surgery (3)
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Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.
Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.
An inpatient fall prevention initiative in a tertiary care hospital.
Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.
Injury and death associated with incidents reported to the Patient Safety Net.
Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.
The no-fall zone.
Butcher L. Hosp Health Netw. June 2013.
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2015.
Inpatient fall prevention: use of in-room Webcams.
Hardin SR, Dienemann J, Rudisill P, Mills KK. J Patient Saf. 2013;9:29-35.
Chronic kidney disease adversely influences patient safety.
Seliger SL, Zhan M, Hsu VD, Walker LD, Fink JC. J Am Soc Nephrol. 2008;19:2414-2419.
Centers for Medicare & Medicaid Services.
Fall prevention in acute care hospitals: a randomized trial.
Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.
Meeting the Joint Commission's 2013 National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
SPECIAL OR THEME ISSUE
J Safety Res. 2011;42:415-542.
Medicare nonpayment, hospital falls, and unintended consequences.
Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.
Serious Reportable Events in Massachusetts Acute Care Hospitals: 2011–2013.
Biondolillo M. Executive Office of Health and Human Services, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; August 2014.
Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.
Shorr RI, Chandler AM, Mion LC, et al. Ann Intern Med. 2012;157:692-699.
Inpatient fall prevention programs as a patient safety strategy: a systematic review.
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.
Is it possible to identify risks for injurious falls in hospitalized patients?
Mion LC, Chandler AM, Waters TM, et al. Jt Comm J Qual Patient Saf. 2012;38:408-413.
To reduce patient falls, hospitals try alarms, more nurses.
Ryan J. All Things Considered. National Public Radio. October 16, 2013.
At risk care plans: a way to reduce readmissions and adverse events.
Bahle J, Majercik C, Ludwick R, Bukosky H, Frase D. J Nurs Care Qual. 2014 Dec 10; [Epub ahead of print].
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.
Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.
Adverse Health Events in Minnesota: Eleventh Annual Public Report.
St. Paul, MN: Minnesota Department of Health; February 2015.
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