U.S. Department of Health & Human Services
Culture of Safety
PATIENT SAFETY PRIMERS
Missed Nursing Care
2014 ANNUAL PERSPECTIVES
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work...
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Device-related Complications (31)
Diagnostic Errors (19)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (45)
Fatigue and Sleep Deprivation (8)
Medication Safety (142)
Medical Complications (106)
Nonsurgical Procedural Complications (20)
Surgical Complications (90)
Transfusion Complications (3)
Psychological and Social Complications (60)
Australia and New Zealand (19)
Central and South America (2)
North America (865)
Clinical Guideline (1)
Journal Article (725)
Newspaper/Magazine Article (96)
Press Release/Announcement (4)
Special or Theme Issue (35)
Web Resource (25)
Epidemiology of Errors and Adverse Events (126)
Active Errors (88)
Latent Errors (128)
Near Miss (16)
Approach to Improving Safety
Culture of Safety
Learning Organization (58)
Red Rules (2)
Institutional Patient Safety Plan (28)
Just Culture (28)
Allied Health Services (3)
Health Care Providers (597)
Health Care Executives and Administrators (942)
Non-Health Care Professionals (525)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (29)
Ambulatory Care (68)
Outpatient Surgery (5)
Patient Transport (10)
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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.
Identifying organizational cultures that promote patient safety.
Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311.
A case for safety leadership team training of hospital managers.
Singer SJ, Hayes J, Cooper JB, et al. Health Care Manage Rev. 2011;36:1-13.
Trainees' perceptions of patient safety practices: recounting failures of supervision.
Ross PT, McMyler ET, Anderson SG, et al. Jt Comm J Qual Patient Saf. 2011;37:88-95.
Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2012;22:118-126.
That’s the way we do things around here!
ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.
Reducing hospital errors: interventions that build safety culture.
Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.
The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study.
Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. Infect Control Hosp Epidemiol. 2010;31:901-907.
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.
Analysis of staff safety concerns.
Davidson J, Lamontagne G, Burnell L, et al. J Nurs Care Qual. 2013;28:147-152.
Patient safety climate in 92 US hospitals: differences by work area and discipline.
Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Med Care. 2009;47:23-31.
Hospital governance and the quality of care.
Jha AK, Epstein AM. Health Aff (Millwood). 2010;29:182-187.
SPECIAL OR THEME ISSUE
Front-Line Ownership: Generating a Cure Mindset for Patient Safety.
Kitts J, ed. Healthcare Papers. 2013;13:1-82.
Physicians with multiple patient complaints: ending our silence.
Gallagher TH, Levinson W. BMJ Qual Saf. 2013;22:521-524.
Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.
Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.
Preventing violence in the health care setting.
Sentinel Event Alert. June 3, 2010;(45):1-3.
A strategic approach for managing conflict in hospitals: responding to The Joint Commission leadership standard—part 1 and part 2.
Scott C, Gerardi D. Jt Comm J Qual Patient Saf. 2011;37:59-69, 70-80.
Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.
Chase D, McCarthy D. Quality Matters. April/May 2010.
Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards.
Schyve PM. San Diego, CA: Governance Institute; 2009.
Exploring relationships between patient safety culture and patients' assessments of hospital care.
Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. J Patient Saf. 2012;8:131-139.
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