-
1
-
-
85185368322
-
-
Institute of Medicine: To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press
-
Institute of Medicine: To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999.
-
(1999)
-
-
-
2
-
-
18644383685
-
Five years after to Err Is Human: What have we learned?
-
May 18
-
Leape LL, Berwick DM. Five years after To Err Is Human: What have we learned? JAMA. 2005 May 18;293(19):2384-2390.
-
(2005)
JAMA
, vol.293
, Issue.19
, pp. 2384-2390
-
-
Leape, L.L.1
Berwick, D.M.2
-
3
-
-
78650694546
-
Overview of progress in patient safety
-
Pronovost PJ, et al. Overview of progress in patient safety. Am J Obstet Gy-necol. 2011;204(1):5-10.
-
(2011)
Am J Obstet Gy-necol.
, vol.204
, Issue.1
, pp. 5-10
-
-
Pronovost, P.J.1
-
4
-
-
78649439268
-
Temporal trends in rates of patient harm resulting from medical care
-
Nov 25;
-
Landrigan C P, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010 Nov 25;363(22):2124-2134.
-
(2010)
N Engl J Med.
, vol.363
, Issue.22
, pp. 2124-2134
-
-
Landrigan, C.P.1
-
5
-
-
79955615675
-
The ongoing quality improvement journey: Next stop, high reliability
-
Chassin MR, Loeb JM. The ongoing quality improvement journey: Next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-568.
-
(2011)
Health Aff (Millwood).
, vol.30
, Issue.4
, pp. 559-568
-
-
Chassin, M.R.1
Loeb, J.M.2
-
6
-
-
66249101242
-
-
US Agency for Healthcare Research and Quality Apr 2008 Accessed Apr 3, 2013
-
US Agency for Healthcare Research and Quality. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Apr 2008. Accessed Apr 3, 2013. http://www.ahrq.gov/professionals/quality-patient-safety/ quality-resources/hroadvice/index.html.
-
Becoming A High Reliability Organization: Operational Advice for Hospital Leaders
-
-
-
7
-
-
85185358834
-
-
Institute for Healthcare Improvement Mar 8, 2012. Accessed Apr 3, 2013
-
Institute for Healthcare Improvement. Highly Reliable Hospitals: The Work Ahead. Audio program. Mar 8, 2012. Accessed Apr 3, 2013. http://www.ihi.org/ knowledge/Pages/AudioandVideo/WIHIHighlyReliableHospitals.aspx.
-
Highly Reliable Hospitals: The Work Ahead. Audio Program
-
-
-
8
-
-
33746344296
-
Creating high reliability in health care organizations
-
Pronovost PJ, et al. Creating high reliability in health care organizations. Health Serv Res 2006;41(4 Pt 2):1599-1617.
-
(2006)
Health Serv Res
, vol.41
, Issue.4 PART 2
, pp. 1599-1617
-
-
Pronovost, P.J.1
-
9
-
-
84858629632
-
Learning" from other industries. Lessons and challenges for health care organizations
-
Kaissi A. "Learning" from other industries. Lessons and challenges for health care organizations. Health Care Manag (Frederick). 2012;31(1):65-74.
-
(2012)
Health Care Manag (Frederick).
, vol.31
, Issue.1
, pp. 65-74
-
-
Kaissi, A.1
-
10
-
-
84863825417
-
Safety management in different high-risk domains-All the same?
-
Grote G. Safety management in different high-risk domains-All the same? Saf Sci. 2012;50(10):1983-1992.
-
(2012)
Saf Sci.
, vol.50
, Issue.10
, pp. 1983-1992
-
-
Grote, G.1
-
11
-
-
83755181717
-
Becoming a high reliability organization
-
Christianson MK, et al. Becoming a high reliability organization. Crit Care. 2011;15(6):314.
-
(2011)
Crit Care
, vol.15
, Issue.6
, pp. 314
-
-
Christianson, M.K.1
-
12
-
-
84867673152
-
Improving healthcare quality through organizational peer-to-peer assessment: Lessons from the nuclear power industry
-
Pronovost PJ, Hudson DW. Improving healthcare quality through organizational peer-to-peer assessment: Lessons from the nuclear power industry. BMJ Qual Saf. 2012;21(10):872-875.
-
(2012)
BMJ Qual Saf.
, vol.21
, Issue.10
, pp. 872-875
-
-
Pronovost, P.J.1
Hudson, D.W.2
-
14
-
-
85185357337
-
-
Department of Energy Apr 25, 2011. Accessed Apr 3, 2013
-
US Department of Energy. DOE P 450.4A, Integrated Safety Management Policy. Apr 25, 2011. Accessed Apr 3, 2013. https://www.directives.doe.gov/ directives/0450.4-APolicy-a/view.
-
DOE P 450.4A, Integrated Safety Management Policy
-
-
-
15
-
-
85185363183
-
-
Department of Energy, Office of Health, Safety, and Security. Rec. 95-2 Integrated Safety Management. January 17, 1996, Department letter partially accepting Board recommendation 95-2. Accessed Apr 3 2013
-
US Department of Energy, Office of Health, Safety, and Security. Rec. 95-2 Integrated Safety Management. January 17, 1996, Department letter partially accepting Board recommendation 95-2. Accessed Apr 3, 2013. http://www.hss. energy.gov/deprep/archive/rec/95-2.asp.
-
-
-
-
16
-
-
85185365258
-
-
Energy Facility Contractors Group (EFCOG) Department of Energy (DOE) Integrated Safety Management System (ISMS) Accessed Apr 3, 2013
-
Energy Facility Contractors Group (EFCOG)/Department of Energy (DOE) Integrated Safety Management System (ISMS). Safety Culture Task Team Report. Jun 2010. Accessed Apr 3, 2013. http://hssoutreach.doe.gov/doc-uments/ SafetyCulture-201006-Report.pdf.
-
(2010)
Safety Culture Task Team Report. Jun
-
-
-
17
-
-
33746062505
-
-
Institute of Nuclear Power Operations Nov Accessed Apr 3 2013
-
Institute of Nuclear Power Operations. Principles for a Strong Nuclear Safety Culture. Nov 2004. Accessed Apr 3, 2013. http://www.efcog.org/wg/ism-pmi/ docs/Safety-Culture/Dec07/INPO%20PrinciplesForStrong NuclearSafetyCulture.pdf.
-
(2004)
Principles for A Strong Nuclear Safety Culture
-
-
-
18
-
-
55949096227
-
Revealing and resolving patient safety defects: The impact of leadership WalkRounds on frontline caregiver assessments of patient safety
-
Frankel A, et al. Revealing and resolving patient safety defects: The impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res. 2008;43(6):2050-2066.
-
(2008)
Health Serv Res.
, vol.43
, Issue.6
, pp. 2050-2066
-
-
Frankel, A.1
-
19
-
-
0037264382
-
Patient Safety Leadership WalkRounds
-
Frankel A, et al. Patient Safety Leadership WalkRounds. Jt Comm J Qual Saf. 2003;29(1):16-26.
-
(2003)
Jt Comm J Qual Saf.
, vol.29
, Issue.1
, pp. 16-26
-
-
Frankel, A.1
-
20
-
-
77955117452
-
Physician leadership: Essential in creating a culture of safety
-
Gluck PA. Physician leadership: Essential in creating a culture of safety. Clin Obstet Gynecol. 2010;53(3):473-481.
-
(2010)
Clin Obstet Gynecol.
, vol.53
, Issue.3
, pp. 473-481
-
-
Gluck, P.A.1
-
21
-
-
32944482207
-
Patient Safety Leadership WalkRounds at Partners Healthcare: Learning from implementation
-
Frankel A, et al. Patient Safety Leadership WalkRounds at Partners Healthcare: Learning from implementation. Jt Comm J Qual Patient Saf. 2005;31(8):423-437.
-
(2005)
Jt Comm J Qual Patient Saf.
, vol.31
, Issue.8
, pp. 423-437
-
-
Frankel, A.1
-
22
-
-
5644300386
-
Eliminating catheter-related bloodstream infections in the intensive care unit
-
Berenholtz SM, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014-2020.
-
(2004)
Crit Care Med.
, vol.32
, Issue.10
, pp. 2014-2020
-
-
Berenholtz, S.M.1
-
24
-
-
85185364561
-
-
US Agency for Healthcare Research and Quality Simmons D. Sep 2011. Accessed Apr 3 2013
-
US Agency for Healthcare Research and Quality. Central, Not Epidural. WebM&M: Morbidity and Mortality Rounds on the Web. Simmons D. Sep 2011. Accessed Apr 3, 2013. http://www.webmm.ahrq.gov/printviewCase.aspx? caseID=250.
-
Central, Not Epidural. WebM&M: Morbidity and Mortality Rounds on the Web
-
-
-
25
-
-
84857582674
-
A matter of conscience: A call to action for system improvements involving epidural and spinal catheters
-
Birnbach DJ, Vincent CA. A matter of conscience: A call to action for system improvements involving epidural and spinal catheters. Anesth Analg. 2012;114(3):494-496.
-
(2012)
Anesth Analg.
, vol.114
, Issue.3
, pp. 494-496
-
-
Birnbach, D.J.1
Vincent, C.A.2
-
26
-
-
79953826380
-
Smart pumps: Implications for nurse leaders
-
Kirkbride G, Vermace B. Smart pumps: Implications for nurse leaders. Nurs Adm Q. 2011;35(2):110-118.
-
(2011)
Nurs Adm Q.
, vol.35
, Issue.2
, pp. 110-118
-
-
Kirkbride, G.1
Vermace, B.2
-
27
-
-
84876944274
-
-
US Food and Drug Administration (Updated: Apr 22, 2010.) Accessed Apr 3, 2013
-
US Food and Drug Administration. Infusion Pump Improvement Initiative. (Updated: Apr 22, 2010.) Accessed Apr 3, 2013. http://www.fda.gov/ MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevices andSupplies/InfusionPumps/ucm202501.htm.
-
Infusion Pump Improvement Initiative
-
-
-
28
-
-
84857294598
-
A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center
-
Tran M, et al. A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center. Jt Comm J Qual Patient Saf. 2012;38(3):112-119.
-
(2012)
Jt Comm J Qual Patient Saf.
, vol.38
, Issue.3
, pp. 112-119
-
-
Tran, M.1
-
29
-
-
0038805213
-
Programming errors contribute to death from patient-controlled analgesia: Case report and estimate of probability
-
Vicente KJ, et al. Programming errors contribute to death from patient-controlled analgesia: Case report and estimate of probability. Can J Anaesth. 2003;50(4):328-332.
-
(2003)
Can J Anaesth.
, vol.50
, Issue.4
, pp. 328-332
-
-
Vicente, K.J.1
-
30
-
-
0003552764
-
-
Center for Chemical Process Safety 2nd ed. New York City: Wiley-American Institute of Chemical Engineers
-
Center for Chemical Process Safety, Destree KB, et al. Guidelines for Hazard Evaluation Procedures, with Worked Examples, 2nd ed. New York City: Wiley-American Institute of Chemical Engineers, 1992.
-
(1992)
Guidelines for Hazard Evaluation Procedures, with Worked Examples
-
-
Destree, K.B.1
-
31
-
-
77957742551
-
A practical guide to failure mode and effects analysis in health care: Making the most of the team and its meetings
-
Ashley L, et al. A practical guide to failure mode and effects analysis in health care: Making the most of the team and its meetings. Jt Comm J Qual Patient Saf. 2010;36(8):351-358.
-
(2010)
Jt Comm J Qual Patient Saf.
, vol.36
, Issue.8
, pp. 351-358
-
-
Ashley, L.1
-
33
-
-
80053446858
-
Implementation of checklists in healthcare: Learning from high-reliability organisations
-
Oct 3;
-
Thomassen Ø, et al. Implementation of checklists in healthcare: Learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med. 2011 Oct 3;19(53):1-7.
-
(2011)
Scand J Trauma Resusc Emerg Med.
, vol.19
, Issue.53
, pp. 1-7
-
-
Thomassen Ø1
-
34
-
-
59449089116
-
A surgical safety checklist to reduce morbidity and mortality in a global population
-
Jan 29
-
Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-499.
-
(2009)
N Engl J Med.
, vol.360
, Issue.5
, pp. 491-499
-
-
Haynes, A.B.1
-
35
-
-
33845880922
-
An intervention to decrease catheter-related bloodstream infections in the ICU
-
Dec 28
-
Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-2732.
-
(2006)
N Engl J Med.
, vol.355
, Issue.26
, pp. 2725-2732
-
-
Pronovost, P.1
-
36
-
-
85185365481
-
-
Australian and New Zealand College of Anaesthetists Annual Meeting, Perth, Australia. May 12-16, 2012. Abstract 456. Accessed Apr 3, 2013
-
Goulding G. A generic smartphone/tablet app for anaesthesia checklists. Australian and New Zealand College of Anaesthetists Annual Meeting, Perth, Australia. May 12-16, 2012. Abstract 456. Accessed Apr 3, 2013. http://www.anzca.edu.au/events/ANZCA%20annual%20scientific%20 meetings/2012-anzca-annual-scientific-meeting/eposter-sessions-2012/ asm-2012-456.pdf.
-
A Generic Smartphone/tablet App for Anaesthesia Checklists
-
-
Goulding, G.1
-
37
-
-
84875221482
-
Surgical never events in the United States
-
Mehtsun WT, et al. Surgical never events in the United States. Surgery. 2013;153(4):465-472.
-
(2013)
Surgery.
, vol.153
, Issue.4
, pp. 465-472
-
-
Mehtsun, W.T.1
-
39
-
-
85185359826
-
-
Department of Energy Aug 2, 2004. Accessed Apr 3, 2013
-
US Department of Energy. DOE P 450.7, Environment, Safety and Health (ESH) Goals. Aug 2, 2004. Accessed Apr 3, 2013. https://www.directives.doe.gov/ directives/0450.7-APolicy/view.
-
DOE P 450.7, Environment, Safety and Health (ESH) Goals
-
-
-
40
-
-
0004223940
-
-
New York City: Cambridge University Press
-
Reason J. Human Error. New York City: Cambridge University Press, 1990.
-
(1990)
Human Error
-
-
Reason, J.1
-
41
-
-
33750328584
-
-
Committee On Identifying And Preventing Medication Errors, Institute of Medicine Washington, DC: National Academies Press
-
Committee on Identifying and Preventing Medication Errors, Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academies Press, 2007.
-
(2007)
Preventing Medication Errors
-
-
-
42
-
-
85185363133
-
-
The Florida Senate, Committee on Health Regulation Nov Florida Patient Safety Corporation. Accessed Apr 3 2013
-
The Florida Senate, Committee on Health Regulation. Interim Project Report 2008-136. Nov 2007. Florida Patient Safety Corporation. Accessed Apr 3, 2013. http://archive.flsenate.gov/data/Publications/2008/Senate/reports/interim- reports/pdf/2008-136hr.pdf.
-
(2007)
Interim Project Report 2008-136
-
-
-
43
-
-
34547503984
-
How a system for reporting medical errors can and cannot improve patient safety
-
Clarke JR, et al. How a system for reporting medical errors can and cannot improve patient safety. Am Surg. 2006;72(11):1088-1091.
-
(2006)
Am Surg.
, vol.72
, Issue.11
, pp. 1088-1091
-
-
Clarke, J.R.1
-
44
-
-
84896820280
-
-
National Association of Boards of Pharmacy Accessed Apr 3, 2013
-
National Association of Boards of Pharmacy. Home page. Accessed Apr 3, 2013. http://www.nabp.net.
-
Home Page
-
-
-
45
-
-
84879227440
-
-
US Department of Veterans Affairs (VA) Washington, DC: VA, Jul 19, 2012. Accessed Apr 3, 2012
-
US Department of Veterans Affairs (VA). Magnetic Resonance Imaging Safety. Washington, DC: VA, Jul 19, 2012. Accessed Apr 3, 2012. http://www.va.gov/vhapublications/ViewPublication.asp?pub-ID=2768.
-
Magnetic Resonance Imaging Safety
-
-
-
46
-
-
39749200238
-
Can medical simulation and team training reduce errors in labor and delivery?
-
Birnbach DJ, Salas E. Can medical simulation and team training reduce errors in labor and delivery? Anesthesiol Clin 2008;26(1):159-168.
-
(2008)
Anesthesiol Clin
, vol.26
, Issue.1
, pp. 159-168
-
-
Birnbach, D.J.1
Salas, E.2
-
47
-
-
14344263564
-
Educating surgery residents in patient safety
-
Sachdeva AK, Blair PG. Educating surgery residents in patient safety. Surg Clin North Am. 2004;84(6):1669-1698.
-
(2004)
Surg Clin North Am.
, vol.84
, Issue.6
, pp. 1669-1698
-
-
Sachdeva, A.K.1
Blair, P.G.2
-
48
-
-
84869808427
-
Creating a common patient safety denominator: The interns' course
-
Shekhter I, et al. Creating a common patient safety denominator: The interns' course. J Grad Med Educ. 2009;1(2):269-272.
-
(2009)
J Grad Med Educ.
, vol.1
, Issue.2
, pp. 269-272
-
-
Shekhter, I.1
-
49
-
-
84876803444
-
Overall burden of bloodstream infection and noso-comial bloodstream infection in North America and Europe
-
Epub 2013 Feb 26
-
Goto M, Al-Hasan MN. Overall burden of bloodstream infection and noso-comial bloodstream infection in North America and Europe. Clin Microbiol Infect. Epub 2013 Feb 26.
-
Clin Microbiol Infect
-
-
Goto, M.1
Al-Hasan, M.N.2
-
51
-
-
62149142125
-
Diagnostic errors-The next frontier for patient safety
-
Mar 11
-
Newman-Toker DE, Pronovost PJ. Diagnostic errors-The next frontier for patient safety. JAMA. 2009 Mar 11;301(10):1060-1062.
-
(2009)
JAMA
, vol.301
, Issue.10
, pp. 1060-1062
-
-
De, N.1
Pronovost, P.J.2
-
52
-
-
78751486325
-
National health spending projections: The estimated impact of reform through 2019
-
Sisko AM, et al. National health spending projections: The estimated impact of reform through 2019. Health Aff (Millwood). 2010;29(10):1933-1941.
-
(2010)
Health Aff (Millwood).
, vol.29
, Issue.10
, pp. 1933-1941
-
-
Sisko, A.M.1
-
53
-
-
84863931455
-
Science-based training in patient safety and quality
-
Jul 17
-
Pronovost PJ, Weisfeldt ML. Science-based training in patient safety and quality. Ann Intern Med. 2012 Jul 17;157(2):141-143.
-
(2012)
Ann Intern Med.
, vol.157
, Issue.2
, pp. 141-143
-
-
Pronovost, P.J.1
Weisfeldt, M.L.2
|