U.S. Department of Health & Human Services
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient...
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Device-related Complications (3)
Diagnostic Errors (2)
Identification Errors (7)
Discontinuities, Gaps, and Hand-Off Problems (17)
Fatigue and Sleep Deprivation (1)
Medication Safety (10)
Medical Complications (17)
Nonsurgical Procedural Complications (9)
Surgical Complications (50)
Transfusion Complications (1)
Psychological and Social Complications (5)
Australia and New Zealand (6)
North America (190)
Journal Article (186)
Newspaper/Magazine Article (14)
Press Release/Announcement (1)
Special or Theme Issue (7)
Web Resource (4)
Epidemiology of Errors and Adverse Events (27)
Active Errors (16)
Latent Errors (27)
Near Miss (2)
Approach to Improving Safety
Health Care Providers (139)
Health Care Executives and Administrators (167)
Non-Health Care Professionals (150)
Setting of Care
Residential Facilities (1)
Ambulatory Care (7)
Outpatient Surgery (1)
Patient Transport (1)
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Mark My Limb.
O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.
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.
Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care.
van der Nelson HA, Siassakos D, Bennett J, et al. Am J Med Qual. 2014;29:78-82.
Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.
Arriaga AF, Gawande AA, Raemer DB, et al; Harvard Surgical Safety Collaborative. Ann Surg. 2014;259:403-410.
From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.
Paige J, Kozmenko V, Morgan B, et al. J Surg Educ. 2007;64:369-377.
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
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.
Association between implementation of a medical team training program and surgical mortality.
Neily J, Mills PD, Young-Xu Y, et al. JAMA
Does teamwork improve performance in the operating room? A multilevel evaluation.
Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-142.
Communication failure in the operating room.
Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.
Briefing and debriefing in the operating room using fighter pilot crew resource management.
McGreevy JM, Otten TD. J Am Coll Surg. 2007;205:169-176.
Effect of a comprehensive surgical safety system on patient outcomes.
de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. N Engl J Med. 2010;363:1928-1937.
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.
Patient safety: break the silence.
Johnson HL, Kimsey D. AORN J. 2012;95:591-601.
The 'second victims' of medication errors begin to gain support.
Blum K. Pharm Pract News. November 2011.
Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress.
Sevdalis N, Hull L, Birnbach DJ. Br J Anaesth. 2012;109:i3-i16.
Incorrect surgical procedures within and outside of the operating room.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.
Nurok M, Evans LA, Lipsitz S, Satwicz P, Kelly A, Frankel A. BMJ Qual Saf. 2011;20:237-242.
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