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 (18)
Identification Errors (15)
Discontinuities, Gaps, and Hand-Off Problems (53)
Fatigue and Sleep Deprivation (8)
Medication Safety (142)
Medical Complications (103)
Nonsurgical Procedural Complications (21)
Surgical Complications (90)
Transfusion Complications (2)
Psychological and Social Complications (56)
Australia and New Zealand (19)
Central and South America (2)
North America (853)
Clinical Guideline (1)
Journal Article (703)
Newspaper/Magazine Article (95)
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Special or Theme Issue (34)
Web Resource (31)
Epidemiology of Errors and Adverse Events (104)
Active Errors (86)
Latent Errors (125)
Near Miss (15)
Approach to Improving Safety
Culture of Safety
Learning Organization (50)
Red Rules (2)
Institutional Patient Safety Plan (25)
Just Culture (29)
Allied Health Services (3)
Health Care Providers (599)
Health Care Executives and Administrators (922)
Non-Health Care Professionals (508)
Setting of Care
Psychiatric Facilities (4)
Residential Facilities (27)
Ambulatory Care (56)
Outpatient Surgery (5)
Patient Transport (9)
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Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
That’s the way we do things around here!
ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.
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.
Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?
Myers JS, Nash DB. Acad Med. 2014;89:1328-1330.
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.
Communication practices on 4 Harvard surgical services: a surgical safety collaborative.
ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.
The inevitability of physician burnout: implications for interventions.
Montgomery A. Burnout Res. 2014;1:50-56.
Get me out alive.
Feldman R. The Washington Post. May 2, 2006:HE01.
Charting the Course: Launching Patient-Centric Healthcare.
Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.
Patient safety attitudes of paediatric trainee physicians.
Parry G, Horowitz L, Goldmann D. Qual Saf Health Care. 2009;18:462-466.
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 systems approach to morbidity and mortality conference.
Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.
Housestaff and medical student attitudes toward medical errors and adverse events.
Vohra PD, Johnson JK, Daugherty CK, Wen M, Barach P. Jt Comm J Qual Patient Saf. 2007;33:493-501.
AHA-NPSF Comprehensive Patient Safety Leadership Fellowship.
American Hospital Association, National Patient Safety Foundation.
A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.
Singh R, Naughton B, Taylor JS, et al. Med Educ. 2005;39:1195-1204.
Reducing hospital errors: interventions that build safety culture.
Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.
Teaching but not learning: how medical residency programs handle errors.
Hoff TJ, Pohl H, Bartfield J. J Org Behav. 2006;27:869-896.
Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.
Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.
Risk mitigation in large scale systems: lessons from high reliability organizations.
Grabowski M, Roberts KH. Calif Manage Rev. 1997;39:152-162.
A patient safety objective structured clinical examination.
Singh R, Singh A, Fish R, McLean D, Anderson DR, Singh G. J Patient Saf. 2009;5:55-60.
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