U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Voluntary Patient Safety Event Reporting (Incident Reporting)
2014 ANNUAL PERSPECTIVES
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Device-related Complications (5)
Diagnostic Errors (6)
Identification Errors (3)
Discontinuities, Gaps, and Hand-Off Problems (7)
Fatigue and Sleep Deprivation (2)
Medication Safety (53)
Medical Complications (13)
Nonsurgical Procedural Complications (3)
Surgical Complications (5)
Transfusion Complications (2)
Psychological and Social Complications (11)
Australia and New Zealand (7)
North America (112)
Journal Article (143)
Newspaper/Magazine Article (14)
Special or Theme Issue (2)
Web Resource (1)
Epidemiology of Errors and Adverse Events (68)
Active Errors (27)
Latent Errors (11)
Near Miss (16)
Approach to Improving Safety
Allied Health Services (1)
Health Care Providers (89)
Health Care Executives and Administrators (154)
Non-Health Care Professionals (67)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (5)
Ambulatory Care (7)
Outpatient Surgery (1)
Patient Transport (2)
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Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.
Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.
Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.
Call RJ, Burlison JD, Robertson JJ, et al. 2014;165:447-452.
Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.
Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2007;334;79.
Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.
Commers T, Swindells S, Sayles H, Gross AE, Devetten M, Sandkovsky U. J Antimicrob Chemother. 2014;69:262-267.
Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.
Valenstein PN, Raab SS, Walsh MK. Arch Pathol Lab Med. 2006;130:1106-1113.
The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.
Leffler DA, Kheraj R, Garud S, et al. Arch Intern Med. 2010;170:1752-1757.
Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"?
Soleimani F. N Z Med J. 2006;119:U2099.
Our long journey towards a safety-minded just culture. Part I: Where we've been.
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2006;11:1-3.
Adverse events in healthcare: learning from mistakes.
Rafter N, Hickey A, Condell S, et al. QJM. 2014 Jul 29; [Epub ahead of print].
Key Issues in Developing a Successful Hospital Safety Program
Whittington J. AHRQ WebM&M [serial online]. July 2006.
Lessons learned: use of event reporting by nurses to improve patient safety and quality.
Hession-Laband E, Mantell P. J Pediatr Nurs. 2011;26:149-155.
Effective strategies to increase reporting of medication errors in hospitals.
Force MV, Deering L, Hubbe J, et al. J Nurs Adm. 2006;36:34-41.
Evaluation of the contributions of an electronic web-based reporting system: enabling action.
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
Physician perception of hospital safety and barriers to incident reporting.
Schectman JM, Plews-Ogan ML. Jt Comm J Qual Patient Saf. 2006;32:337-343.
Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.
The need for organizational change in patient safety initiatives.
Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. Int J Med Inform. 2006;75:809-817.
Rates and types of events reported to established incident reporting systems in two US hospitals.
Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Qual Saf Health Care. 2007;16:164-168.
Getting doctors to report medical errors: project DISCLOSE.
King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ. Jt Comm J Qual Patient Saf. 2006;32:382-392.
Health care provider use of private sector internal error-reporting systems.
Roumm AR, Sciamanna CN, Nash DB. Am J Med Qual. 2005;20:304-312.
Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
Provenzano A, Rohan S, Trevejo E, Burdick E, Lipsitz S, Kachalia A. BMJ Qual Saf. 2015;24:31-37.
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