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 (13)
Identification Errors (16)
Discontinuities, Gaps, and Hand-Off Problems (41)
Fatigue and Sleep Deprivation (8)
Medication Safety (133)
Medical Complications (99)
Nonsurgical Procedural Complications (19)
Surgical Complications (110)
Transfusion Complications (3)
Psychological and Social Complications (55)
Australia and New Zealand (19)
Central and South America (2)
North America (850)
Clinical Guideline (1)
Journal Article (705)
Newspaper/Magazine Article (94)
Press Release/Announcement (4)
Special or Theme Issue (35)
Web Resource (27)
Epidemiology of Errors and Adverse Events (107)
Active Errors (96)
Latent Errors (121)
Near Miss (18)
Approach to Improving Safety
Culture of Safety
Learning Organization (41)
Red Rules (3)
Institutional Patient Safety Plan (18)
Just Culture (31)
Allied Health Services (4)
Health Care Providers (617)
Health Care Executives and Administrators (925)
Non-Health Care Professionals (500)
Setting of Care
Psychiatric Facilities (3)
Residential Facilities (27)
Ambulatory Care (56)
Outpatient Surgery (5)
Patient Transport (11)
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Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.
Creating a culture of safety by using checklists.
Huang L, Kim R, Berry W. AORN J. 2013;97:365-368.
Bringing surgeons down to earth.
Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.
Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
Doctor uses 'pre-flight' checklist.
Bernhard B. The Orange County Register. April 19, 2006.
Wrong body part, wrong patient surgeries continue despite new procedures.
Rojas-Burke J. The Oregonian. May 25, 2011.
Can aviation-based team training elicit sustainable behavioral change?
Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.
The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.
Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.
Patient safety in the obstetric and gynecologic office setting.
Keats JP. Obstet Gynecol Clin North Am. 2013;40:611-623.
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Improving patient safety: patient-focused, high-reliability team training.
McKeon LM, Cunningham PD, Detty Oswaks JS. J Nurs Care Qual. 2009;24:76-82.
Crew resource management improved perception of patient safety in the operating room.
Gore DC, Powell JM, Baer JG, et al. Am J Med Qual. 2010;25:60-63.
Retained surgical items and minimally invasive surgery.
Gibbs VC. World J Surg. 2011;35:1532-1539.
SPECIAL OR THEME ISSUE
Quality of Anesthesia Care.
Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.
"Managing up" can improve teamwork in the OR.
Smith SL. AORN J. 2010;91:576-582.
Recommendations for Safe Use of Insulin in Hospitals.
Bethesda, MD: American Society of Health-System Pharmacists; 2006.
Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views.
McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Qual Saf Health Care. 2005;14:290-294.
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.
Bridging the communication gap in the operating room with medical team training.
Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.
Video technology to advance safety in the operating room and perioperative environment.
Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.
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