U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
Device-related Complications (7)
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Identification Errors (19)
Discontinuities, Gaps, and Hand-Off Problems (123)
Fatigue and Sleep Deprivation (127)
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Laboratory Result Tracking Improvement (65)
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Setting of Care
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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.
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.
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.
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.
2009 National Patient Safety Goals.
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
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.
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. 2011 Oct 31; [Epub ahead of print].
Safe practice environment chapter proposed by USP.
ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.
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.
Safely implementing health information and converging technologies.
Sentinel Event Alert. December 11, 2008;(42):1-4.
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.
Improving the discharge process by embedding a discharge facilitator in a resident team.
Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.
Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.
Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.
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