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 (31)
Diagnostic Errors (19)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (45)
Fatigue and Sleep Deprivation (8)
Medication Safety (141)
Medical Complications (107)
Nonsurgical Procedural Complications (20)
Surgical Complications (88)
Transfusion Complications (3)
Psychological and Social Complications (55)
Australia and New Zealand (19)
Central and South America (2)
North America (860)
Clinical Guideline (1)
Journal Article (714)
Newspaper/Magazine Article (93)
Press Release/Announcement (4)
Special or Theme Issue (35)
Web Resource (28)
Epidemiology of Errors and Adverse Events (108)
Active Errors (88)
Latent Errors (127)
Near Miss (16)
Approach to Improving Safety
Culture of Safety
Learning Organization (57)
Red Rules (2)
Institutional Patient Safety Plan (28)
Just Culture (28)
Allied Health Services (3)
Health Care Providers (598)
Health Care Executives and Administrators (934)
Non-Health Care Professionals (526)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (27)
Ambulatory Care (68)
Outpatient Surgery (5)
Patient Transport (9)
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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.
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.
Identifying organizational cultures that promote patient safety.
Singer SJ, Falwell A, Gaba DM, et al. Health Care Manage Rev. 2009;34:300-311.
Reducing hospital errors: interventions that build safety culture.
Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.
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.
Leadership in Healthcare Organizations: A Guide to Joint Commission Leadership Standards.
Schyve PM. San Diego, CA: Governance Institute; 2009.
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.
The Role of HR in Quality and Patient Safety.
The American Society for Healthcare Human Resources Administration. San Diego, CA: July 24, 2008.
Second Victim: Error, Guilt, Trauma, and Resilience.
Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.
Creating a culture of safety.
Bush H. Trustee Magazine. July 2013.
Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety.
Frankel A, Grillo SP, Pittman M, et al. Health Serv Res. 2008;43:2050-2066.
Safety leadership: a meta-analytic review of transformational and transactional leadership styles as antecedents of safety behaviours.
Clarke S. J Occup Organ Psychol. 2013;86:22-49.
Promoting a culture of safety as a patient safety strategy: a systematic review.
Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Ann Intern Med. 2013;158(5 Pt 2):369-374.
Integrating CUSP and TRIP to improve patient safety.
Romig M, Goeschel C, Pronovost P, Berenholtz SM. Hosp Pract (Minneap). 2010;38:114-121.
AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.
Blegen MA, Gearhart S, O'Brien R, Sehgal NL, Alldredge BK. J Patient Saf. 2009;5:139-144.
Patient-Centered Care Improvement Guide.
Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
SPECIAL OR THEME ISSUE
Front-Line Ownership: Generating a Cure Mindset for Patient Safety.
Kitts J, ed. Healthcare Papers. 2013;13:1-82.
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.
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