U.S. Department of Health & Human Services
Audit and Feedback
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (18)
Diagnostic Errors (33)
Identification Errors (7)
Discontinuities, Gaps, and Hand-Off Problems (35)
Fatigue and Sleep Deprivation (4)
Medication Safety (112)
Medical Complications (53)
Nonsurgical Procedural Complications (8)
Surgical Complications (37)
Transfusion Complications (1)
Psychological and Social Complications (4)
Australia and New Zealand (10)
North America (224)
Journal Article (284)
Newspaper/Magazine Article (29)
Special or Theme Issue (3)
Web Resource (3)
Epidemiology of Errors and Adverse Events (125)
Active Errors (79)
Latent Errors (32)
Near Miss (5)
Approach to Improving Safety
Audit and Feedback
Allied Health Services (1)
Health Care Providers (233)
Health Care Executives and Administrators (296)
Non-Health Care Professionals (114)
Setting of Care
Residential Facilities (5)
Ambulatory Care (32)
Outpatient Surgery (6)
Patient Transport (1)
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Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.
National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.
Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.
Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.
Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.
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.
The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.
Lubomski LH, Marsteller JA, Hsu YJ, et al. Jt Comm J Qual Patient Saf. 2008;34:619-623.
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
Temporal trends in rates of patient harm resulting from medical care.
Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.
Medication Safety Self Assessment for Automated Dispensing Cabinets.
Horsham, PA: Institute for Safe Medication Practices; 2009.
Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.
Ramsay AI, Turner S, Cavell G, et al. BMJ Qual Saf. 2014;23:136-146.
Hospital discharge documentation and risk of rehospitalisation.
Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.
Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.
O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.
The safety of hospital stroke care.
Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.
Analysis of staff safety concerns.
Davidson J, Lamontagne G, Burnell L, et al. J Nurs Care Qual. 2013;28:147-152.
National Diabetes Inpatient Audit 2011.
Leeds, UK: Health and Social Care Information Centre; 2012.
Collaboration focused on priority issues promotes safety.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Professionalism: a necessary ingredient in a culture of safety.
DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.
Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S. Am J Infect Control. 2014;42:106-110.
Physician implicit review to identify preventable errors during in-hospital cardiac arrest.
Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.
Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.
Balla U, Malnick S, Schattner A. Medicine (Baltimore). 2008;87:294-300.
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