U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (30)
Diagnostic Errors (27)
Identification Errors (25)
Discontinuities, Gaps, and Hand-Off Problems (30)
Fatigue and Sleep Deprivation (4)
Medication Safety (172)
Medical Complications (85)
Nonsurgical Procedural Complications (8)
Surgical Complications (74)
Transfusion Complications (7)
Psychological and Social Complications (62)
Australia and New Zealand (39)
North America (566)
Journal Article (512)
Newspaper/Magazine Article (91)
Press Release/Announcement (10)
Special or Theme Issue (7)
Web Resource (27)
Epidemiology of Errors and Adverse Events (235)
Active Errors (123)
Latent Errors (53)
Near Miss (37)
Approach to Improving Safety
Governmental Reporting (70)
Institutional Reporting (96)
Nongovernmental Reporting (14)
Patient Disclosure (146)
Patient Complaints (64)
Never Events (49)
Allied Health Services (3)
Complementary and Alternative Medicine (1)
Health Care Providers (465)
Health Care Executives and Administrators (645)
Non-Health Care Professionals (369)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (15)
Ambulatory Care (52)
Outpatient Surgery (15)
Patient Transport (4)
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Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2015.
Adverse Events in Hospitals: Overview of Key Issues.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.
Hospital patient safety grades may misrepresent hospital performance.
Hwang W, Derk J, LaClair M, Paz H. J Hosp Med. 2014;9:111-115.
The partnership with patients: a call to action for leaders.
Denham CR. J Patient Saf. 2011;7:113-121.
Hospital Reporting Program.
Portland, OR: Oregon Patient Safety Commission.
Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.
Vaida AJ, Lamis RL, Smetzer JL, Kenward K, Cohen MR. Jt Comm J Qual Patient Saf. 2014;40:51-67.
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Centers for Medicare & Medicaid Services.
Assessing and improving quality and safety.
Zeis M. HealthLeaders Media. July/August 2013;16:26-28.
NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.
DerGurahian J. Mod Healthc. June 16, 2008;38:6.
Patient Safety in Canada: An Update.
Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.
Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.
Kavanagh KT. Soc Work Public Health. 2011;26:524-541.
The next organizational challenge: finding and addressing diagnostic error.
Graber ML, Trowbridge R, Myers JS, Umscheid CA, Strull W, Kanter MH. Jt Comm J Qual Patient Saf. 2014;40:102-110.
National Healthcare Safety Network.
Centers for Disease Control and Prevention.
Standing Up for Doctors, Speaking Out for Patients. Final Report.
London, UK: Health Policy & Economic Research Unit, British Medical Association Scotland; May 2010.
"That was a close call": endorsing a broad definition of near misses in health care.
Marks CM, Kasda E, Paine L, Wu AW. Jt Comm J Qual Patient Saf. 2013;39:475-479.
Common formats for patient safety data collection and event reporting.
Federal Register. Rockville, MD: Agency for Healthcare Research and Quality. February 18, 2014;79:9214-9215.
Adverse Events in Hospitals: State Reporting Systems.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471.
Diagnostic error in acute care.
PA-PSRS Patient Saf Advis. 2010;7:76-86.
Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.
Davies EC, Green CF, Mottram DR, Pirmohamed M. Br J Clin Pharmacol. 2010;70:102-108.
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