U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (33)
Diagnostic Errors (39)
Identification Errors (23)
Discontinuities, Gaps, and Hand-Off Problems (130)
Fatigue and Sleep Deprivation (4)
Medication Safety (469)
Medical Complications (61)
Nonsurgical Procedural Complications (6)
Surgical Complications (41)
Transfusion Complications (9)
Psychological and Social Complications (8)
Australia and New Zealand (20)
North America (852)
Journal Article (693)
Newspaper/Magazine Article (137)
Press Release/Announcement (1)
Special or Theme Issue (24)
Web Resource (9)
Epidemiology of Errors and Adverse Events (244)
Active Errors (145)
Latent Errors (90)
Near Miss (12)
Approach to Improving Safety
Automatic drug dispensers (42)
Bar Coding and Radiofrequency ID Tagging (95)
Computerized Adverse Event Detection (95)
Computer-Assisted Therapy (4)
Clinical Information Systems (494)
Health Care Providers (575)
Health Care Executives and Administrators (778)
Non-Health Care Professionals (609)
Setting of Care
Residential Facilities (9)
Ambulatory Care (128)
Outpatient Surgery (5)
Patient Transport (2)
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Improvement of medication event interventions through use of an electronic database.
Merandi J, Morvay S, Lewe D, et al. Am J Health Syst Pharm. 2013;70:1708-1714.
Safe practice environment chapter proposed by USP.
ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.
The computerized rounding report: implementation of a model system to support transitions of care.
Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.
Computer viruses are "rampant" on medical devices in hospitals.
Talbot D. MIT Technology Review. October 17, 2012.
Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.
Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.
Journey to no preventable risk: The Baylor Health Care System patient safety experience.
Kennerly D, Richter KM, Good V, Compton J, Ballard DJ. Am J Med Qual. 2011;26:43-52.
Design and implementation of an automated email notification system for results of tests pending at discharge.
Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.
Inpatient fall prevention: use of in-room Webcams.
Hardin SR, Dienemann J, Rudisill P, Mills KK. J Patient Saf. 2013;9:29-35.
Smart pumps: advanced capabilities and continuous quality improvement.
Vanderveen T. Patient Saf Quality Healthc. January/February 2007.
Patient safety: the synergy of technology and behavior.
Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.
Leadership practices to advance patient safety.
Crowley JD, Deen JB. Patient Saf Qual Healthc. May/June 2009;6:18-22.
Implementing patient safety initiatives in rural hospitals.
Klingner J, Moscovice I, Tupper J, Coburn A, Wakefield M. J Rural Health. 2009;25:352-357.
Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication.
Siracuse JJ, Benoit E, Burke J, Carter S, Schwaitzberg SD. Jt Comm J Qual Patient Saf. 2014;40:126-133.
Are we finally getting serious about medical errors?
Burns J. Managed Care Magazine. May 2011;20:23-28.
Can wearable tech prevent healthcare errors?
Reese SM. Information Week. March 11, 2014.
Improving Patient Safety Through Simulation Research.
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
Medication Safety Self Assessment for Automated Dispensing Cabinets.
Horsham, PA: Institute for Safe Medication Practices; 2009.
Anticoagulant safety practices call for pharmacist supervision.
Scott A. Drug Topics (Health-System Edition). November 10, 2008.
Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.
ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.
2009 Utah Sentinel Events Data Report.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
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