U.S. Department of Health & Human Services
Culture of Safety
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work...
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Device-related Complications (30)
Diagnostic Errors (20)
Identification Errors (14)
Discontinuities, Gaps, and Hand-Off Problems (45)
Fatigue and Sleep Deprivation (7)
Medication Safety (139)
Medical Complications (104)
Nonsurgical Procedural Complications (21)
Surgical Complications (88)
Transfusion Complications (2)
Psychological and Social Complications (58)
Australia and New Zealand (18)
Central and South America (2)
North America (852)
Clinical Guideline (1)
Journal Article (710)
Newspaper/Magazine Article (98)
Press Release/Announcement (4)
Special or Theme Issue (34)
Web Resource (26)
Epidemiology of Errors and Adverse Events (111)
Active Errors (93)
Latent Errors (142)
Near Miss (16)
Approach to Improving Safety
Culture of Safety
Learning Organization (53)
Red Rules (2)
Institutional Patient Safety Plan (24)
Just Culture (30)
Allied Health Services (4)
Health Care Providers (589)
Health Care Executives and Administrators (927)
Non-Health Care Professionals (537)
Setting of Care
Psychiatric Facilities (5)
Residential Facilities (27)
Ambulatory Care (57)
Outpatient Surgery (5)
Patient Transport (9)
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Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.
Gaba DM. Calif Manage Rev. 2000;43:1-20.
Creating a culture of safety.
Bush H. Trustee Magazine. July 2013.
Communication-and-resolution programs: the challenges and lessons learned from six early adopters.
Mello MM, Boothman RC, McDonald T, et al. Health Aff (Millwood). 2014;33:20-29.
Minnesota Hospital Association Statewide Project: SAFE from FALLS.
Apold J, Quigley PA. J Nurs Care Qual. 2012;27:299-306.
Organizational culture as a source of high reliability.
Weick KE. Calif Manage Rev. 1987;29:112-127.
Creating a culture of safety in the emergency department: the value of teamwork training.
Jones F, Podila P, Powers C. J Nurs Adm. 2013;43:194-200.
Tennessee Center for Patient Safety.
The silent treatment: 'just be quiet about it'.
Smerd J. Workforce Management. November 19, 2007;1, 16-20.
"Second victim" casualties and how physician leaders can help.
MacLeod L. Physician Exec. Jan-Feb 2014;40:8-12.
Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support.
Shapiro J, Whittemore A, Tsen LC. Jt Comm J Qual Patient Saf. 2014;40:168-177.
The new recommendations on duty hours from the ACGME Task Force.
Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.
SPECIAL OR THEME ISSUE
Front-Line Ownership: Generating a Cure Mindset for Patient Safety.
Kitts J, ed. Healthcare Papers. 2013;13:1-82.
Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.
Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.
Reducing hospital errors: interventions that build safety culture.
Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.
Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.
Patterson ME, Pace HA, Fincham JE. J Patient Saf. 2013;9:129-133.
Stories from the sharp end: case studies in safety improvement.
McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.
Chasing Zero: Winning the War on Healthcare Harm.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
Organizational culture, critical success factors, and the reduction of hospital errors.
Stock GN, McFadden KL, Gowen III, CR. Int J Prod Econ. 2007;106:368–392.
Plan aims to cut hospital deaths.
Appleby J. USA Today. June 6, 2005.
The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.
Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.
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