U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (7)
Diagnostic Errors (22)
Identification Errors (19)
Discontinuities, Gaps, and Hand-Off Problems (125)
Fatigue and Sleep Deprivation (131)
Medication Safety (127)
Medical Complications (53)
Nonsurgical Procedural Complications (6)
Surgical Complications (43)
Transfusion Complications (5)
Psychological and Social Complications (15)
Australia and New Zealand (12)
North America (446)
Journal Article (405)
Newspaper/Magazine Article (62)
Special or Theme Issue (8)
Web Resource (2)
Epidemiology of Errors and Adverse Events (115)
Active Errors (61)
Latent Errors (78)
Near Miss (8)
Approach to Improving Safety
Laboratory Result Tracking Improvement (65)
Nurse Staffing Ratios (55)
Scheduling Changes (36)
Duty Hour Limitation (145)
Health Care Providers (357)
Health Care Executives and Administrators (398)
Non-Health Care Professionals (205)
Setting of Care
Psychiatric Facilities (1)
Residential Facilities (6)
Ambulatory Care (43)
Outpatient Surgery (3)
Patient Transport (4)
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Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.
Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. J Acad Nutr Diet. 2012;112:1656-1661.
Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.
Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.
Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.
McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.
The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care.
Dai H, Milkman KL, Hofmann DA, Staats BR. J Appl Psychol. 2014 Nov 3; [Epub ahead of print].
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.
Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.
Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.
O'Leary KJ, Sehgal NL, Terrell G, Williams MV; High Performance Teams and the Hospital of the Future Project Team. J Hosp Med. 2012;7:48-54.
The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.
Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.
2009 National Patient Safety Goals.
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.
Taylor JA, Dominici F, Agnew J, Gerwin D, Morlock L, Miller MR. BMJ Qual Saf. 2012;21:101-111.
Safe practice environment chapter proposed by USP.
ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.
Safely implementing health information and converging technologies.
Sentinel Event Alert. December 11, 2008;(42):1-4.
Safe Practices for Better Healthcare–2009 Update.
National Quality Forum. Washington, DC: National Quality Forum; 2009.
Safety of using a computerized rounding and sign-out system to reduce resident duty hours.
Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.
Putting the 'patient' in patient safety: a qualitative study of consumer experiences.
Rathert C, Brandt J, Williams ES. Health Expect. 2012;15:327-336.
Scariest hospital risks.
Herper M, Lindner M. Forbes. August 25, 2008.
Meeting the Joint Commission's 2013 National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.
Mortality rate after nonelective hospital admission.
Ricciardi R, Roberts PL, Read TE, Baxter NN, Marcello PW, Schoetz DJ. Arch Surg. 2011;146:545-551.
Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations.
Sehgal NL, Green A, Vidyarthi AR, Blegen MA, Wachter RM. J Hosp Med. 2010;5:234-239.
Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.
Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.
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