RESOURCES BY TOPIC

INDEX of TOPICS:
A - C	C - H	H - M	M - R	R - Z
Accreditation and Safety Standards Adult Hospitals and the Care of Children Adverse Event Detection and Trigger Tools Alarm Fatigue Alert Fatigue Ambulatory Care Anaesthesia Anaphylaxis Antibiotic Resistance Awards and Success Stories Bar Code Medication Administration (BCMA) Beds and Cribs Big Data and Predictive Analytics Business Case for Patient Safety Cardiology Change Management Child Abuse Child Health in the Community Child Safety and Injury Prevention Child Survival in Developing Countries Clinical Decision Support System (CDSS) Clinical Effectiveness and Standardisation Clinical Pathways Clinical References Communication	Continuous Improvement and Lean Continuous Monitoring CPR and Resuscitation Critical Care Daily Goals Deterioration Developing Countries and Resource-Poor Settings Diagnosis Disaster Preparedness Discharge Timeliness Disclosure Disparities and Equity Duty Hours Ebola Education and Training eHealth, mHealth, and Telehealth Eliminating Preventable Harm Emergency Care Emergency Medical Services (EMS) Employee Safety Flow General/Community Hospitals Global Child Health Haematology/Oncology Hand Hygiene Handoffs and Communication Health IT Health Literacy	High Reliability and HROs Hospital Acquired Conditions (HACs): - ADE - CAUTI - CLABSI - Falls - OB-AE - PIVIE - PU - SSI - Unplanned Extubations - VAP - VTE Hospital Acquired Infections (HAIs) Hospital at Night (HaN) Hospital Design Huddles Human Factors Journals Junior Doctors Leadership Malpractice Medical Devices Medical Emergency Team (MET) Medical Errors Medication Safety	Mental Health Mislabeled Specimens Morbidty and Mortality (M&M) Rounds National Patient Safety Board Neonatal Intensive Care Unit (NICU) Neonatal-Perinatal Never Events Opioids Paediatric Early Warning System (PEWS) Paediatric Intensive Care Unit (PICU) Pain Patient and Family Engagement Patient Identification Patient Safety Indicators (PSIs) Patient Safety Priority Areas Peer-to-Peer (P2P) Assessment Poisoning Prevention Precision Public Health Prehospital Care Primary Care Quality Measures Radiation in Imaging Rapid Response Team (RRT) Readmissions and Care Transitions Reporting Researcher-in-Residence Resident Physicians	Resuscitation Reverse Innovation Root Cause Analysis (RCA) Safety Culture Safety-II and Resilience Second Victim Sentinel Events Sepsis Serious Safety Events (SSEs) Simulation Situation Awareness Sleep and SIDS Staffing Standardisation of Care Surgery Teamwork Training Telemedicine Transport Trigger Tools Triple Aim Tubing Misconnections Universal Health Coverage Unplanned Extubations Walkrounds Weekend Effect Work Environment Zika

RESOURCES by TOPIC:
Accreditation and Safety Standards	ACSQHC - accreditation and the NSQHS standards ISQua - International Accreditation Programme (IAP) Joint Commission International (JCI) Patient mortality during unannounced accreditation surveys at US hospitals PIPSQC - protecting children from harm - setting standards: a view from Australia (slides) PIPSQC - protecting children from harm - setting standards: a view from the UK (slides) SafeCare - SafeCare Standards - for health centres in resource-restricted settings Secret data on hospital inspections may soon become public Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial When clinicians know they're being watched, patients fare better
Adult Hospitals and the Care of Children	Emergency Department: AAP - joint policy statement - guidelines for care of children in the emergency department CMS - PfP library - guidelines for care of children in the emergency department Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU National assessment of pediatric readiness of emergency departments National Pediatric Readiness Project (Peds Ready) - ensuring emergency care for all children National Pediatric Readiness Project (Peds Ready) - readiness toolkit Inpatient: AAP - Section on Hospital Medicine (SOHM) - elibrary Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions CMS - PfP - resources CMS - PfP library - adverse drug event priority areas for pediatric patients CMS - PfP library - care of children in general hospitals CMS - PfP library - children are not little adults CMS - PfP library - ensuring pediatric safety in general hospitals CMS - PfP library - PFE (patient and family engagement) guidelines for pediatric patients in adult hospitals CMS - PfP library - resource list for pediatric safe care HRET - Hospital Engagement Network (HEN) 2.0 - topics Pediatric medication safety in adult community hospital settings: a glimpse into nationwide practice UHN - Caring Safely (slides)
Adverse Event Detection and Trigger Tools	Adverse Drug Events: 30-day potentially avoidable readmissions due to adverse drug events Adverse drug event reporting systems: a systematic review Assessing frequency and risk of weight entry errors in pediatrics Automated detection of look-alike/sound-alike medication errors Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database CHA - saving lives and reducing medication errors with data Clinical decision support for drug related events: moving towards better prevention IHI - pediatric trigger toolkit: measuring adverse drug events in the children's hospital IHI - trigger tool for measuring adverse drug events Learning from the design, development and implementation of the Medication Safety Thermometer Looking for safety insights in medication order changes National trends in safety performance of electronic health record systems in children's hospitals NHS - Medication Safety Thermometer Screening for medication errors using an outlier detection system Electronic: Assessing frequency and risk of weight entry errors in pediatrics Automated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions Automated detection of adverse events in children Big data applied to patient safety in children's hospitals Casting a wider safety net: the promise of electronic safety event detection systems CHA - what big data means for pediatrics Developing and evaluating an automated all-cause harm trigger system Development of an electronic pediatric all-cause harm measurement tool using a modified delphi method Electronic approaches to making sense of the text in the adverse event reporting system Innovative use of the electronic health record to support harm reduction efforts IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety National trends in safety performance of electronic health record systems in children's hospitals New 'trigger tool' scans EMRs for harms in pediatric hospitals Pediatric hospitals show wide gap in EHR safety performance Screening electronic health record–related patient safety reports using machine learning Emergency Department: Adverse event and error of unexpected life-threatening events within 24h of emergency department admission Development of an emergency department trigger tool using a systematic search and modified delphi process Inpatient: Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study Application of the global trigger tool: a systematic review CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review CPSI - Canadian Paediatric Adverse Events Study (CPAES) Designing highly reliable adverse-event detection systems to predict subsequent claims Development of the Canadian paediatric trigger tool for identifying potential adverse events Development of a pediatric adverse events terminology Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU Families as partners in hospital error and adverse event surveillance IHI - introduction to trigger tools for identifying adverse events IHI - paediatric trigger tool for measuring adverse events (UK version) IHI - perinatal trigger tool IHI - trigger tool for measuring adverse events in the neonatal intensive care unit Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach NHS - Children and Young People's Services (C&YPS) Safety Thermometer NHS - Children and Young People's Services (C&YPS) Safety Thermometer - guidance NHS - Neonatal Trigger Tool (NTT) NHS - organisation patient safety incident reports NHS - Paediatric Trigger Tool (PTT) NHS - Safety Thermometer (Classic) Operational failures detected by frontline acute care nurses Pediatric terminology files - "pediatric adverse events terminology" Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the paediatric trigger tool Trigger tool to detect harm in pediatric inpatient settings Outpatient: CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review IHI - outpatient adverse event trigger tool Patient safety incidents are common in primary care: a national prospective active incident reporting survey Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis Safety incidents in the primary care office setting Sick children crying for help: fostering adverse event reports General: Canadian hospitals can reduce risk of patient harm, report says CIHI - 1 in 18 patients experiences harm in Canadian hospitals CIHI - hospital harm project CPSI - hospital harm indicator CPSI - measuring patient harm in Canadian hospitals Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands Estimating deaths due to medical error: the ongoing controversy and why it matters Estimating hospital-related deaths due to medical error: a perspective from patient advocates Health Foundation - framework for measuring and monitoring safety Health Foundation - measurement and monitoring of safety Hospital Safety Grade - lives lost and lives saved Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement IOM - to err is human - building a safer health system Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals - a retrospective record review study ISMP - using information from external errors to signal a "clear and present danger" Measurement as a performance driver: the case for a national measurement system to improve patient safety Measuring harm in health care: optimizing adverse event review Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study Medical error-the third leading cause of death in the US NHS England - Development of the Patient Safety Incident Management System (DPSIMS) Performance of a trigger tool for identifying adverse events in oncology Study on medical error as third cause of US deaths criticized as 'precarious' Stunning news on preventable deaths in hospital Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events Why are medical errors still a leading cause of death?
Alarm Fatigue	Paediatric: Big data applied to patient safety in children's hospitals Development of heart and respiratory rate percentile curves for hospitalized children Framework for reducing alarm fatigue on pediatric inpatient units Frequency of physiologic monitor alarms in a children's hospital Predictive analytics: heading off the alarms at Boston Children’s Hospital Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital General: ACCN - strategies for managing alarm fatigue AHRQ PSNet - reducing the safety hazards of monitor alert and alarm fatigue Alarm fatigue: use of an evidence-based alarm management strategy Ambient Clinical Analytics - AWARE - addressing the information overload issue to reduce risk and improve patient outcomes Bernoulli - alarm management Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU How redesigning the abrasive alarms of hospital soundscapes can save lives New for 2016: Joint Commission updates alarm guidelines NPSF - surveillance monitoring for all Raising an alarm, doctors fight to yank hospital ICUs into the modern era
Alert Fatigue	Clinical reasoning in the context of active decision support during medication prescribing Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system Evaluation of medication-related clinical decision support alert overrides in the intensive care unit Optimization of drug-drug interaction alert rules in a pediatric hospital's EHR using a visual analytics dashboard Screen flashes and pop-up reminders: ‘alert fatigue’ spreads through medicine
Ambulatory Care	AAP - Practice Improvement Network (PIN) Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project AHRQ - guide to improving patient safety in primary care settings by engaging patients and families AHRQ - making health care safer in ambulatory care settings and long term care facilities (grant) AHRQ - taking steps to protect safety in ambulatory care Annotated bibliography: understanding ambulatory care practices in the context of patient safety and quality improvement CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review How to monitor patient safety in primary care Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care Medication errors in outpatient pediatrics NPSF - creating structure for sharing information and knowledge in ambulatory care: two exemplars NPSF - swinging the patient safety pendulum to primary care Patient safety in ambulatory care Patient safety in ambulatory settings Patient safety incidents are common in primary care: a national prospective active incident reporting survey Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis Preventing diagnostic errors in primary care Role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice Safety incidents in the primary care office setting Sick children crying for help: fostering adverse event reports Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports Taking steps to protect safety in ambulatory care WHO - safer primary care WHO - technical series on safer primary care
Anaesthesia	A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong APSF - monitoring for opioid-induced ventilatory impairment (OIVI) Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study Certified registered nurse anesthetist perceptions of factors impacting patient safety Development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis Interventions guided by analysis of quality indicators decrease the frequency of laryngospasm during pediatric anesthesia Managing Emergencies in Paediatric Anaesthesia (MEPA) Medication safety in the operating room: literature and expert-based recommendations Monitoring the anaesthetist in the operating theatre-professional competence and patient safety National pediatric anesthesia safety quality improvement program in the United States PIPSQC - to sleep perchance to dream - quality in pediatric anesthesia Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome? Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system Society for Pediatric Anesthesia (SPA) Wake Up Safe - pediatric anesthesia quality improvement initiative What parents should know about the use of general anesthesia in toddlers
Anaphylaxis	15 per cent of kids who have an anaphylactic reaction have delayed second reaction: study Determining current insulin pen use practices and errors in the inpatient setting Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis Lacerations and embedded needles caused by epinephrine autoinjector use in children Medication errors in the management of anaphylaxis in a pediatric emergency department
Antibiotic Resistance	5 ways you can help prevent the post-antibiotic era Antimicrobial resistance Antimicrobial stewardship and patient safety CDC - antibiotic / antimicrobial resistance CDC - pressing fast forward on patient safety Cooperative high reliability organization: approaching a zero-defect culture Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative IDSA - antimicrobial resistance MRSA rates dropped 87% in VA hospital ICUs New hope in superbug fight: Tasmanian devil milk NPSF - five ways to take action against antibiotic resistance NQF - antibiotic stewardship playbook NQF - NQF, CDC issue guidance to help hospitals better manage use of antibiotics Science world is freaking out over this 25-year-old's answer to antibiotic resistance 'Superbug' scourge spreads as U.S. fails to track rising human toll Superbugs: the $100 trillion risk UN adopts declaration on antimicrobial resistance WHO - antimicrobial resistance WHO - evolving threat of antimicrobial resistance - options for action WHO - global action plan on antimicrobial resistance WHO - guidelines on core components of infection prevention and control programmes at the national and acute health care facility level WHO - WHO publishes list of bacteria for which new antibiotics are urgently needed
Awards and Success Stories	Africa: Nelson Mandela Children’s Hospital Trust - about us (South Africa) Nelson Mandela Children’s Hospital Trust to bring state-of-the-art healthcare to the children of Africa SickKids - SickKids and the Nelson Mandela Children's Hospital Asia: KK Women's and Children's Hospital - patient safety - building a reliable culture for a sustainable outcome Europe: Getting better: the inside track on improving Great Ormond Street Hospital Great Ormond Street Hospital for Children (GOSH) - quality improvement Health Foundation - pursuing zero - a winning approach to safety NHS England - integrated digital care record - success story: safer hospitals, safer wards technology fund (Nottingham University Hospitals) North America: AHA - Children's Colorado - Target Zero: data and a personal touch to improve young patients' safety AHA - Nationwide Children's - reducing harm is great: eliminating it is the ultimate goal AHA - HPOE - Children's Colorado and Nationwide Children's quality and safety journey (slides) AHA - HPOE - Children's Colorado and Nationwide Children's quality and safety journey (webinar) AHA - HPOE - profiles in excellence: quality improvement lessons from the AHA-Mckesson Quest for Quality Prize recipients part 1 AHRQ - impact case studies AHRQ - improving patient safety through learning laboratories 'Being the best at getting better' - creating a culture of change (Cincinnati Children's) Building a high-reliability organization: one system's patient safety journey CHA - 4 quality improvement ideas hospitals can implement CHA - 2015 Pediatric Quality Award entries (by hospital) Children's Colorado - always improving: what we measure and how we do it Eliminating preventable harm to patients and staff (SickKids) John M. Eisenberg Patient Safety and Quality Awards OHMCH celebrates 365 days without a serious safety event Nationwide Children's - Nationwide Children's hospital receives award from CHA for 'Zero Hero' patient safety program NPSF - awards PIPSQC - mission possible (high reliability at Rainbow Children's) PIPSQC - Target Zero at Children’s Colorado: eliminating preventable harm SickKids - Caring Safely - our journey to eliminating preventable harm 'We're not going to compete on safety': Canadian paediatric health centres collaborate on journey to eliminating preventable harm
Bar Code Medication Administration (BCMA)	Bar code Rx administration compliance rolling out slowly Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification Comparison of medication safety systems in critical access hospitals: combined analysis of two studies Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework Effect of barcode-assisted medication administration on emergency department medication errors Effects of bar-coding technology on medication errors: a systematic literature review Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events Improved supply chain in Canadian health system can save lives NPSF - medication barcode optimization OhioHealth improves patient safety with processes and advanced technologies Pediatric medication administration errors and workflow following implementation of a bar code medication administration system Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode Supermarket-style scanners could make health care safer: study WIN - visibility: the new value proposition for health systems WIN - visibility: the new value proposition for health systems (slides) WIN - visibility: the new value proposition for health systems - executive summary
Beds and Cribs	FDA pediatric hospital bed regulations FDA - summary: general hospital and personal use devices: renaming of pediatric hospital bed classification and designation of special controls for pediatric medical crib; classification of medical bassinet (proposed rule)
Big Data and Predictive Analytics	Paediatric: Big data applied to patient safety in children's hospitals CHA - what big data means for pediatric patients Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children Isansys - available now - new data driven approach to healthcare Looking for safety insights in medication order changes PEDSnet Precision public health: big data's next big idea Predictive analytics: heading off the alarms at Boston Children’s Hospital General: Big data in healthcare made simple: where it stands today and where it’s going Finding the missing link for big biomedical data Perspectives on big data, ethics, and society
Business Case for Patient Safety	Paediatric: Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population CHA - investing in children should be a national priority Children's Hospitals' Solutions for Patient Safety (SPS) - our results Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2016) Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2015) Children's Hospitals' Solutions for Patient Safety (SPS) - Ohio Children's Hospitals release results of Ohio patient safety collaboration; demonstrate national impact of work Cincinnati Children's - CERT - learning network health care outcomes Comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system NPSF - making quality and safety a priority in health care for our children Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement General: AHRQ - national patient safety efforts save 125,000 lives and nearly $28 billion in costs AHRQ - national quality strategy - making care safer AHRQ - national scorecard on rates of hospital-acquired conditions 2010 to 2015: interim data from national efforts to make health care safer AHRQ - saving lives and saving money: hospital-acquired conditions update - interim data from national efforts to make care safer, 2010-2014 AHRQ - we're keeping score: reducing hospital-acquired conditions Canadian hospitals can reduce risk of patient harm, report says CIHI - hospital harm project CMS awards $347 million to continue progress toward a safer health care system CMS - continuing to improve patient safety in hospitals CMS - Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 - final report CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm Cost-benefit analysis of a support program for nursing staff Deaths by medical mistakes hit records Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review Economic impact of medication error: a systematic review Federal ministry of health - economics of patient safety: strengthening a value-based approach to reducing patient harm at national level From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals HHS.gov - national patient safety efforts save 87,000 lives and nearly $20 billion in costs Hospital Engagement Network Results Show 34,000 Harms Prevented Hospital Safety Grade - lives lost and lives saved IHI/NPSF - optimizing a business case for safe health care: an integrated approach to safety and finance IHI/NPSF - webcast: business case for patient safety Impact of inpatient harms on hospital finances and patient clinical outcomes Impact of medical errors and malpractice on health economics, quality, and patient safety Impact of Medicare's nonpayment program on hospital-acquired conditions Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System New study shows financial benefit of improving patient safety NPSF - preventable health care harm is a public health crisis PIPSQC - patient harm is a public health crisis, not just a performance management issue Preventable harm in healthcare a public health crisis Scottish Government - 20,000 fewer deaths than expected since safety programme launched Stunning news on preventable deaths in hospital
Cardiology	CHA - advancing care for children with heart defects International Children's Heart Foundation (ICHF) - where we operate International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries (IQIC) National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) Pediatric Cardiac Critical Care Consortium (PC4) Save a Child's Heart - global
Change Management	Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups IHI - sustaining improvement Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature Highly Adoptable Improvement Model HIS - QI Connect - high leading and networking for change How to create change that sticks and spreads How hospital workers solve patient-safety problems on their own IGNITE Consulting Promising contributions of behavioral economics to quality improvement in health care Slow ideas What we know about designing an effective improvement intervention (but too often fail to put into practice)
Child Abuse	AAP - Section on Child Abuse and Neglect (SOCAN) Child abuse evaluation & treatment for medical providers - a-z index Child maltreatment: a public health overview and prevention considerations End Violence Against Children - The Global Partnership HSCIC - Child Protection – Information Sharing project (CP-IS) International Society for the Prevention of Child Abuse and Neglect (ISPCAN) RCPCH - child protection UNICEF - child protection from violence, exploitation and abuse
Child Health in the Community	AAP - healthychildren.org Canada, the kids are not alright CHA - adults say kids' health is worse than the past CHA - investing in the future of children's health CHA - lessons learned in the first 18 months of the CARE Award to transform care and payment models CHA - health care model that prevents childhood obesity Cincinnati Children Thrive Learning Network (CCTLN) IHI - 100 Million Healthier Lives ihub Scotland - support in the community - Scottish Patient Safety Programme - maternity and children's care International Pediatric Association (IPA) - children's environmental health and the sustainable development goals National Center for Education in Maternal and Child Health (NCEMCH) - professional resource guides and briefs National Institute for Children’s Health Quality (NICHQ) - project topic areas NHS Choices - child health tools NPSF - preventable health care harm is a public health crisis Patient safety: a public health crisis for a nation of patients PIPSQC Blog - patient harm is a public health crisis, not just a performance management issue Preventable harm in healthcare a public health crisis Scottish Government - Early Years Collaborative (EYC) Scottish Government - Getting it Right for Every Child (GIRFEC) SickKids - AboutKidsHealth Speak Now for Kids - Advancing Care for Exceptional Kids Act of 2015 (ACE Kids Act) WHO - cost of a polluted environment: 1.7 million child deaths a year, says WHO
Child Safety and Injury Prevention	CAPHC - new CPS position statement: The prevention of firearm injuries in Canadian youth CDC - national action plan for child injury prevention CHA - give families the tools to store firearms safely Children's Safety Network (CSN) - injury topics Children's Safety Network (CSN) - Child Safety Collaborative Innovation and Improvement Network (CS COIIN) KidsAndCars.org Safe Kids Worldwide Safe Kids Worldwide: preventing unintentional childhood injuries across the globe SickKids - a child is injured by a firearm every day in Ontario: study WHO - child injuries and violence WHO - international and regional child safety organizations WHO - more than 1.2 million adolescents die every year, nearly all preventable
Child Survival in Developing Countries	Maternal, Newborn, and Child Survival: Adoption of recommended practices and basic technologies in a low-income setting Bill & Melinda Gates Foundation - maternal, newborn & child health CAPHC - Pocket Doc for Pneumonia: top 10 Google.org impact challenge finalist Coalition of Centres in Global Child Health DCP3 - reproductive, maternal, newborn, and child health - key messages Delivering for mothers and newborns: ending preventable maternal and newborn deaths Ending Preventable Child and Maternal Deaths - A Promise Renewed (APR) Every Newborn Every Woman, Every Child Every Woman, Every Child - launch of global accelerated action for the health of adolescents (AA-HA!): guidance to support country implementation Every Woman, Every Child - transitioning the global strategy for women’s and children’s health for the post-2015 era Gavi - global vaccine alliance - progress reports Global burden of diseases for young people's health during 1990-2013 Healthy Newborn Network (HNN) Healthy Newborn Network (HNN) - saving newborn lives - champions toolkit Helping Babies Breathe International Pediatric Association (IPA) - child survival International Pediatric Association (IPA) - children's environmental health and the sustainable development goals International Pediatric Association (IPA) - joint statements - managing possible serious bacterial infection in young infants 0-59 days old when referral is not feasible Jhpiego Johns Hopkins School of Public Health receives $20 million grant from the Bill & Melinda Gates Foundation to improve third world maternal and child health Laerdal Global Health Maikhanda Trust (Malawi) Nelson Mandela Children’s Hospital Trust - reduce child mortality in Sub-Saharan Africa OPENPediatrics - addressing child survival globally (webinar) OPENPediatrics - development of triage guidelines for the PICU (South Africa) (webinar) OPENPediatrics - international web-based pediatric knowledge network - resources Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score Save the Children - Saving Newborn Lives (SNL) program Saving Lives at Birth SDGs: start with maternal, newborn, and child health cluster SickKids Centre for Global Child Health SickKids - Coalition of Centres in Global Child Health Sprinkles Global Health Initiative - to prevent and treat micronutrient deficiencies Towards ending preventable child deaths UCR - maternal, newborn, and child health UN - sustainable development knowledge platform - goal 3: ensure healthy lives and promote well-being for all at all ages UNICEF - narrowing the gaps - the power of investing in the poorest children UNICEF - UNICEF Annual Report 2016 USAID - Alliance for Reproductive, Maternal, and Newborn Health (2010 - 2015) USAID - Every Child Deserves a 5th Birthday - global roadmap USAID - maternal child survival program WHO - almost half of all deaths now have a recorded cause, WHO data show WHO - children: reducing mortality WHO - Collaborating Center for Training and Research in Newborn Care WHO - cost of a polluted environment: 1.7 million child deaths a year, says WHO WHO - Integrated Management of Childhood Illness (IMCI) WHO - joint United Nations statement on ending discrimination in health care settings WHO - management of newborn illness and complications WHO - managing possible serious bacterial infection in young infants when referral is not feasible WHO - maternal, newborn, child and adolescent health WHO - monitoring priorities for the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030) WHO - more than 1.2 million adolescents die every year, nearly all preventable WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline WHO - Partnership for Maternal, Newborn & Child Health (PMNCH) WHO - pocket book of hospital care for children - guidelines for the management of common illnesses with limited resources WHO - PMNCH - PMNCH 2016 annual report WHO - promoting health through the life-course - resources and publications WHO - reaching the Every Newborn national 2020 milestones - country progress, plans and moving forward WHO - world health assembly agrees resolutions on women, children and adolescents, and healthy ageing Worldmapper - infant mortality Patient Safety and Quality: Access Health International - maternal and child health Best Care... Always! (South Africa) Can a quality improvement project impact maternal and child health outcomes at scale in northern Ghana? Federal Ministry of Health - best practices in patient safety: 2nd global ministerial summit on patient safety Federal Ministry of Health - patient safety summit 2017 - patient safety takes the front seat Healthy Newborn Network (HNN) - India part of health network to reduce maternal, newborn deaths IHI - IHI's work in Africa IHI - IHI's work around the world IHI - Project Fives Alive! - reducing under-5 mortality in Ghana Improving the quality of paediatric care in peripheral hospitals in developing countries International Pediatric Association (IPA) - joint statements - improving quality of maternal and newborn care in low- and middle-income countries International Pediatric Association (IPA) - Quality of Care (QoC) ISQua - Improving physician compliance to WHO guidelines for better health of pediatric population Lancet - maternal health - an executive summary for The Lancet's series Nelson Mandela Children’s Hospital Trust - about us (South Africa) OPENPediatrics - leading towards zero harm (webinar) OPENPediatrics - improving safety in the PICU (webinar) OPENPediatrics - Pediatric Clinical Safety Investigation (CSI) - virtual patient safety rounds (#1-8) (webinars) Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review PICC 2016 - pre-congress workshops - global health PICC 2016 - session summaries - global health session Quality of care for pregnant women and newborns - the WHO vision Review of pediatric critical care in resource-limited settings: a look at past, present, and future directions SafeCare - SafeCare Standards - for health centres in resource-restricted settings SickKids - SickKids and the Nelson Mandela Children's Hospital SickKids - SickKids partners with Nelson Mandela Children's Hospital Trust USAID ASSIST Project - maternal, newborn, and child health WHO - African Partnerships for Patient Safety (APPS) WHO - better hospital care for children WHO - consultation on improving measurement of the quality of maternal, newborn and child care in health facilities WHO - hospital care for mothers and newborn babies quality assessment and improvement tool WHO - improving paediatric quality of care at first-level referral hospitals WHO - launch of the network to improve quality of care for mothers, newborns and children WHO - maternal, newborn, child and adolescent health - documents on quality of care WHO - patient safety - implementing change WHO - PMNCH - launch of Network for Improving Quality of Care for Maternal, Newborn and Child Health WHO - quality of care for every pregnant woman and newborn WHO - standards for improving quality of maternal and newborn care in health facilities
Clinical Decision Support System (CDSS)	Ambient Clinical Analytics - Mayo Clinic and tech entrepreneurs join forces to launch Ambient Clinical Analytics, first-ever bedside decision support platform to transform patient critical care American College of Physicians launches ACP Smart Medicine, offering doctors 'one click to confidence' Can computers help doctors reduce diagnostic errors? Clarity Informatics - evidence-based healthcare intelligence Clinical decision support: 25 year retrospective and a 25 year vision Clinical decision support for drug related events: moving towards better prevention Deep learning is a black box, but health care won't mind Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation DXplain decision support system Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system 'Green Button' for using aggregate patient data at the point of care IBM - WatsonPaths Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis Impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients Innovative use of the electronic health record to support harm reduction efforts ISABEL Active Intelligence - diagnosis decision support system Learning health care system using computer-aided diagnosis National trends in safety performance of electronic health record systems in children's hospitals Pediatric hospitals show wide gap in EHR safety performance Screening for medication errors using an outlier detection system Zynx Health announces innovative line of analytic clinical improvement solutions
Clinical Effectiveness and Standardisation	Australia: CareTrack Kids - CareTrack Kids main study conditions CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review NSW Health - Office of Kids and Families - standardisation of care PIPSQC - protecting children from harm - setting standards: a view from Australia (slides) PIPSQC - what percentage of children receive healthcare in line with clinical practice guideline recommendations? Europe: Dartmouth Institute - where children live affects care, exposing some to unnecessary treatment, imaging and medication Health Foundation - creating a new improvement research institute Mapping variation to prioritise areas needing improved outcome, quality and productivity PIPSQC - protecting children from harm - setting standards: a view from the UK (slides) North America: AAP - Choosing Wisely - 10 things physicians and patients should question CAPHC - Canadian Paediatric Decision Support Network (CPDSN) CAPHC - say yes to the less - Choosing Wisely program in a paediatric department Choosing Wisely campaign - don’t throw the baby out with the bathwater Choosing wisely in newborn medicine: five opportunities to increase value Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value Countering cognitive biases in minimising low value care Employer-led health care revolution Is excessive resource utilization an adverse event? Prioritization of comparative effectiveness research topics in hospital pediatrics PRIS - PHIS+: augmenting the pediatric health information system with clinical data PRIS - prioritization project Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support Reducing overuse - is patient safety the answer? Texas Children's hospital improves quality of care, identifies inefficiencies with enterprise data warehouse from Health Catalyst Wennberg International Collaborative - research into causes of unwarranted health care variation Which inpatient pediatric conditions merit priority in comparative effectiveness research? Global: International Consortium for Health Outcomes Measurement (ICHOM) - standard sets
Clinical Pathways	Paediatric: Boston Children's - when the going gets tough, the tough get data: SCAMPs (slides) Children's Hospital of Philadelphia (CHOP) - clinical pathways Cincinnati Children's - Evidence Based Decision Making (EBDM) Clinical pathways - driving high-reliability and high-value care Seattle Children's - clinical standard work pathways and tools Standardized Clinical Assessment and Management Plans (SCAMPs) - pediatric SCAMPs TREKK - ED clinical pathways implementation General: Clarity Informatics - Quality Improvement System (QIS) NHS - Advancing Quality Standardized Clinical Assessment and Management Plans (SCAMPs)
Clinical References	AAP - Pediatric Care Online RCPCH - Paediatric Care Online UK
Communication	See 'Handoffs and Communication'
Continuous Improvement and Lean	Employer-led health care revolution Factory efficiency comes to the hospital Healthier Hospitals Initiative IHI - radically redesigning patient safety Lean Hospitals - Lean Hospitals; improving quality, patient safety, and employee engagement 3rd edition Lean Hospitals - resources Modifying the toyota production system for continuous performance improvement in an academic children's hospital Seattle Children's - CPI book: Leading the lean healthcare journey Seattle Children's - CPI fact sheets Seattle Children's - transformative healthcare via Continuous Performance Improvement (CPI) SickKids - daily Continuous Improvement Program (CIP) SickKids - daily Continuous Improvement Program to provide safer care (slides) Virginia Mason - Virginia Mason production system Waste not, want not - the key to reducing costs
Continuous Monitoring	See 'Critical Care'
CPR and Resuscitation	AAP - updated guidelines address CPR, emergency cardiovascular care Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments Emergency Medical Services for Children (EMSC) National Resource Center - toolboxes Helping Babies Breathe ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients International Liaison Committee on Resuscitation (ILCOR) Monash Children's - pediatric emergency medication book Pediatric Advanced Life Support (PALS) PICC 2016 - session summaries - resuscitation session PIPSQC - keeping kids safe during critical illness and resuscitation Time to epinephrine and survival after pediatric in-hospital cardiac arrest WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline
Critical Care	Clinical Decision Support System (CDSS): Ambient Clinical Analytics - Mayo Clinic and tech entrepreneurs join forces to launch Ambient Clinical Analytics, first-ever bedside decision support platform to transform patient critical care Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures Continuous Monitoring: Ambient Clinical Analytics - AWARE - addressing the information overload issue to reduce risk and improve patient outcomes Birmingham Children's - RAPID (Real-Time Adaptive and Predictive Indicator of Deterioration) Boston Children's Hospital and Etiometry bring T3 patient-monitoring technology to market Etiometry - Tracking, Trajectory, Trigger (T3) intensive care unit software solution Formula 1 technology is helping save childrens lives Health Foundation - continuous remote monitoring of ill children (Birmingham Children's) ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients Insights from multi-dimensional physiological signals to predict and prevent cardiac arrests Isansys - available now - new data driven approach to healthcare Isansys - Isansys wearable technology and wireless patient monitoring platform in at-scale deployment at Birmingham Children's Hospital Monitoring: advanced technology in ICU (slides) NPSF - surveillance monitoring for all Raising an alarm, doctors fight to yank hospital ICUs into the modern era 'Smart pills' help doctors monitor patients from a distance Temporary tattoo that brings hospital care to the home High Reliability: High reliability pediatric intensive care unit OPENPediatrics - leading towards zero harm (webinar) OPENPediatrics - improving safety in the PICU (webinar) PICC 2016 - pre-congress workshops - risky business: critical care RHLN - reliability leadership: examples from a paediatric intensive care unit and the riverside county EMS Learning Networks: CHA - PICU CLABSI collaborative Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions InFACT - mapping critical care - ACCESS MAPS - project to aggregate location of acute care services worldwide OPENPediatrics - international web-based pediatric knowledge network - resources Pediatric Intensive Care Audit Network (PICANet) - audit PedsCCM.org PICC 2016 - pre-congress workshops PICC 2016 - session summaries PICU Journal Watch Review of pediatric critical care in resource-limited settings: a look at past, present, and future directions Set of quality indicators of pediatric intensive care in Spain: Delphi method selection Virtual Pediatric Systems (VPS) - improving critical care quality and outcomes for all children WHO - critical care training short course - clinical management of patients with severe forms of influenza infection World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS)
Daily Goals	Improving communication during cardiac ICU multidisciplinary rounds through visual display of patient daily goals Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit
Deterioration	See 'Paediatric Early Warning System (PEWS)'
Developing Countries and Resource-Poor Settings	See 'Child Survival in Developing Countries'
Diagnosis	Checklists: CARE approach to reducing diagnostic errors Checklists to reduce diagnostic errors Minimizing diagnostic error: 10 things you can do tomorrow SIDM - reducing diagnostic error - health care organizations - ten things I could do tomorrow SIDM - reducing diagnostic error - physicians, PAs, and NPs - ten things I could do tomorrow Clinical Decision Support System (CDSS): American College of Physicians launches ACP Smart Medicine, offering doctors 'one click to confidence' Can computers help doctors reduce diagnostic errors? Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation DXplain decision support system Impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients ISABEL - diagnostic errors ISABEL Active Intelligence - diagnosis decision support system Learning health care system using computer-aided diagnosis Measures: Measures to improve diagnostic safety in clinical practice Medical-legal: CMPA - diagnostic tips - reducing medical-legal difficulties Doctor's Company - diagnostic error in medical practice by specialty Doctor's Company - pediatrics resources Fewer medical malpractice lawsuits succeed, but payouts are up Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014 Paediatric: AAP - Project RedDE!: reducing diagnostic errors in primary care pediatrics Children's Colorado - reducing diagnostic errors Diagnostic error in children presenting with acute medical illness to a community hospital Diagnostic errors in the pediatric and neonatal ICU: a systematic review Diagnostic errors and strategies to minimize them (special issue) Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study Errors of diagnosis in pediatric practice: a multisite survey Finding diagnostic errors in children admitted to the PICU How doctors think: common diagnostic errors in clinical judgment - lessons from an undiagnosed and rare disease program Innovative collaborative model of care for undiagnosed complex medical conditions National physician survey of diagnostic error in paediatrics Overcoming diagnostic errors in medical practice Perspectives from a pediatrician about diagnostic errors PIPSQC - deciphering diagnostic errors in pediatrics Why it's so easy for doctors to misdiagnose kids General: 5 ways to reduce inpatient diagnosis errors 20 percent of patients with serious conditions are first misdiagnosed, study says Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care Addressing the problem of diagnostic errors Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework AHRQ - improving diagnostic safety AHRQ PSNet - annual perspective 2014 - diagnostic errors Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed Deep learning is a black box, but health care won't mind Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error Diagnosis (volume 1, issue 1) Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic Diagnostic error in medicine (special issue) ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error Extent of diagnostic agreement among medical referrals Five simple steps to avoid becoming a medical mystery Hiding in plain sight - resurrecting the power of inspecting the patient Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study Improving diagnosis in health care - the next imperative for patient safety Inpatient notes: reducing diagnostic error-a new horizon of opportunities for hospital medicine IOM - improving diagnosis in healthcare IOM - improving diagnosis in health care: an implementation workshop Johns Hopkins - Center for Diagnostic Excellence Nearly 10 percent of strokes are misdiagnosed (at least initially) in the emergency department NPSF - diagnostic error prevention general resources NQF - improving diagnostic accuracy project 2016-2017 Patient safety strategies targeted at diagnostic errors: a systematic review Potential of collective intelligence in emergency medicine Preventing diagnostic errors in primary care Prognosis of undiagnosed chest pain: linked electronic health record cohort study SIDM - Coalition to Improve Diagnosis SIDM - diagnostic error resources SIDM - diagnostic error measures worksheet SIDM - diagnosis and high reliability (May 2014 issue) SIDM - preventing diagnostic error where do I start webcast (slides) System-related interventions to reduce diagnostic errors: a narrative review Teaching the diagnostic process as a model to improve medical education Unraveling diagnostic error: delving deeply to identify hidden human factors Using automated surveillance to improve diagnosis War on error: common diagnostic errors
Disaster Preparedness	Medical response to multisite terrorist attacks in Paris Simulation to predict effect of citywide events on emergency department operations
Discharge Timeliness	Academy of Fabulous NHS Stuff - improving the time of discharge for patients Royal Hospital for Sick Children, Yorkhill - PICU total delayed discharges (+ 4 hrs) Using quality improvement to optimise paediatric discharge efficiency
Disclosure	AHRQ - Communication and Optimal Resolution (CANDOR) toolkit Applying lessons from social psychology to transform the culture of error disclosure Balancing doctor egos and errors CAPHC - talking to children about medical errors: stakeholder perspectives Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate CPSI - Canadian disclosure guidelines: being open with patients and families Disclosure of adverse events in pediatrics Doctors could admit to mistakes without facing liability in court under proposed legislation Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review Heart of health care: parents' perspectives on patient safety IHI - respectful management of serious clinical adverse events Implementing an error disclosure coaching model: a multicenter case study Improving communication and resolution following adverse events using a patient-created simulation exercise Inpatient Notes: mistakes in the hospital - communicating, apologizing, and beyond Learning through experience: influence of formal and informal training on medical error disclosure skills in residents Parent preferences for medical error disclosure: a qualitative study Pathologists' perspectives on disclosing harmful pathology error PIPSQC - partnering with parents to save children's lives Progress at the intersection of patient safety and medical liability (special issue) "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes Two words can soothe patients who have been harmed: we're sorry
Disparities and Equity	Australia: CareTrack Kids Europe: Dartmouth atlas of care - children's health care Dartmout Institute - where children live affects care, exposing some to unnecessary treatment, imaging and medication Deaths in young people aged 0-24 years in the UK compared with the EU15+ countries, 1970-2008: analysis of the WHO Mortality Database Improving child health services in the UK: insights from Europe and their implications for the NHS reforms Mapping variation to prioritise areas needing improved outcome, quality and productivity NHS - Right Care - NHS atlas of variation in healthcare for children and young adults PIPSQC - protecting children from harm - setting standards: a view from the UK (slides) North America: AHRQ - national healthcare quality & disparities reports Child and adolescent health care quality and disparities: are we making progress? Health Leads - research HRET - Hospital Engagement Network (HEN) 2.0 - health care disparities IHI - achieving health equity: a guide for health care organizations IHI CEO Derek Feeley: "If there is no equity, there is no quality." (video) IOM - unequal treatment: confronting racial and ethnic disparities in health care
Duty Hours	Bipartisan consensus: the public wants well-rested medical residents to help ensure safe patient care Caregiver fatigue: implications for patient and staff safety - part 1 and part 2 Common program requirements. The learning and working environment (duty hours) Ethical considerations in the development of the flexibility in duty hour requirements for surgical trainees trial Health care worker fatigue Latest results from the "FIRST" (Flexibility in Duty Hour Requirements for Surgical Trainees) trial Medical residents angered at extended work hours NPSF - sleep deprivation, health care providers, and patient safety Patient handoffs: is cross cover or night shift better? Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial Resident duty hours and medical education policy-raising the evidence bar Resident work hours and patient safety Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers Summary of proposed changes to ACGME common program requirements section VI Survey says: don't lift limits on residents' hours What is known: examining the empirical literature in resident work hours using 30 influential articles Work systems analysis approach to understanding fatigue in hospital nurses
Ebola	Paediatric: AAP - CDC activates Children's Task Force in response to Ebola outbreak AAP - Ebola outbreak Being a pediatrician in an Ebola epidemic Care of the child with Ebola virus disease CDC - Ebola resources for parents, schools, and pediatric healthcare providers Ebola virus disease and children - what pediatric health care professionals need to know RCPCH - Ebola crisis - resources for paediatricians General: Emory Healthcare launches Ebola protocols website as resource on prevention and patient care Long-term cure for Ebola: an investment in health systems Time person of the year - the Ebola fighters WHO - Ebola virus disease outbreak
Education and Training	Paediatric: CareTrack Kids - CareTrack Adverse Events Program (CAEP) CHA - pediatric learning solutions - online training to foundational clinical information Developing future clinical leaders for quality improvement: experience from a London children's hospital Equipped: introduction to quality improvement in paediatrics and child health Equipped: overcoming barriers to change to improve quality of care (theories of change) G30 developing paediatricians as future clinical leaders: Enabling Doctors in Quality Improvement and Patient Safety (EQuIP) programme design and evaluation Impact of a longitudinal quality improvement and patient safety curriculum on pediatric residents Levine Children's - Center for Advancing Pediatric Excellence resident QI curriculum Nationwide Children's - clinical fellowship in quality and safety leadership RCPCH - Quality Improvement and Patient Safety (QIPS) Running Horse Group - EQUIPPED WFPICCS - Sister PICU Program General: 5 steps to better patient safety training for residents, fellows AHRQ PSNet - annual perspective 2014 - safety and medical education Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers Chief of residents for quality improvement and patient safety: a recipe for a new role in graduate medical education CPME - key findings and recommendations on education and training in patient safety across Europe CUGH - Annotated List of Online Global Health Resources Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences Growth mindset approach to preparing trainees for medical error IHI Open School - online courses in patient safety and improvement capability Improving engagement with patient safety through educational events Making residents part of the safety culture: improving error reporting and reducing harms National report of findings 2016: issue brief No. 2: patient safety New graduate registered nurses' knowledge of patient safety and practice: a literature review NHS - e-learning for healthcare NHS England - Q Initiative NPSF - patient safety curriculum Partnerships, capacity building needed to strengthen universities in developing nations Patient Safety Education Program - Canada (PSEP - Canada) Patient safety and interprofessional education: a report of key issues from two interprofessional workshops Quality and Safety Education for Nurses (QSEN) - QSEN competencies Quality and safety in nursing: a competency approach to improving outcomes, second edition WHO - critical care training short course - clinical management of patients with severe forms of influenza infection WHO - multi-professional patient safety curriculum guide
eHealth, mHealth, and Telehealth	CAPHC - Pocket Doc for Pneumonia: top 10 Google.org impact challenge finalist Children's Hospital of Pittsburgh (CHP) - telemedicine program Commonwealth Fund - mobile health and patient engagement in the safety net: a survey of community health centers and clinics Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU OPENPediatrics - leading towards zero harm (webinar) OPENPediatrics - improving safety in the PICU (webinar) OPENPediatrics - Pediatric Clinical Safety Investigation (CSI) - virtual patient safety rounds (#1-8) (webinars) Saving lives from afar: bridging the knowledge (& distance) gaps in health care with the cloud Telehealth in the developing world: current status and future prospects UHN - Centre for Global eHealth Innovation WHO - 7 day mother baby mCheck tool WHO - Global Observatory for eHealth WHO - impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here? WHO - launch of mHealth toolkit to help innovators scale up projects for reproductive, maternal, newborn, child and adolescent health
Eliminating Preventable Harm	Building a high-reliability organization: one system's patient safety journey Children's Hospitals' Solutions for Patient Safety (SPS) Health care learning networks: widespread effort to eliminate medical errors among kids Improving safety for pediatric patients OHMCH celebrates 365 days without a serious safety event NPSF - making quality and safety a priority in health care for our children SickKids - Caring Safely UHN - Caring Safely (slides) UHN - renewing UHN - Caring Safely UHN - update UHN plans for 2016: Caring Safely
Emergency Care	AAP - joint policy statement - guidelines for care of children in the emergency department Adverse event and error of unexpected life-threatening events within 24h of emergency department admission Ask Me to Explain Campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us CHA - strategies to better serve the emergency department population Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments Early death after discharge from emergency departments: analysis of national US insurance claims data ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis Emergency Medical Services for Children (EMSC) - National Resource Center - toolboxes Emergency room doctors may impact patients' opioid use Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients Identifying high-risk children in the emergency department Identifying and reducing complications after emergency room discharge Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU Implementation of the WHO Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures In situ simulation: detection of safety threats and teamwork training in a high risk emergency department Meds IQ - emergency drug dose calculator Monash Children's - pediatric emergency medication book National assessment of pediatric readiness of emergency departments National Pediatric Readiness Project (Peds Ready) - ensuring emergency care for all children National Pediatric Readiness Project (Peds Ready) - readiness toolkit Nearly 10 percent of strokes are misdiagnosed (at least initially) in the emergency department Opioid-prescribing patterns of emergency physicians and risk of long-term use Patient safety in the emergency department PIPSQC - keeping kids safe during critical illness and resuscitation Potential of collective intelligence in emergency medicine Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score Scoring systems in paediatric emergency care: Panacea or paper exercise? Simulation for operational readiness in a new freestanding emergency department: strategy and tactics Simulation to predict effect of citywide events on emergency department operations TREKK - ED clinical pathways implementation TREKK -translating emergency knowledge for kids Using automated surveillance to improve diagnosis WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline
Emergency Medical Services (EMS)	Center for Patient Safety - EMS patient safety boot camp Elimination of emergency department medication errors due to estimated weights Emergency Medical Services for Children (EMSC) - National Resource Center - toolboxes Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS Pediatric patient safety in emergency medical services Pediatric prehospital medication dosing errors: a mixed-methods study Pediatric prehospital medication dosing errors: a national survey of paramedics PIPSQC - keeping kids safe during critical illness and resuscitation Systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review
Employee Safety	Addressing physician burnout: the way forward AHRQ PSNet - annual perspective 2015 - burnout among health professionals and its effect on patient safety Amazing way this hospital is fighting physician burnout - Code Lavender program Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections Can we talk about physician mental health Caregiver fatigue: implications for patient and staff safety - part 1 and part 2 Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment Center for Patient Safety - second victim experience CHA - reducing employee burnout key to improving quality and safety in health care CHA - strategies for helping employees stay healthy on the job CHA - strategies for supporting employees' mental health Children's Hospitals' Solutions for Patient Safety (SPS) taps Value Capture to expand its life-saving efforts Cincinnati Children's - reduce employee injury Clinician support: five years of lessons learned Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis Cost-benefit analysis of a support program for nursing staff Design of an evidence-based "second victim" curriculum for nurse anesthetists Despite burnout, there's still joy in medicine Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout Doctors, hospitals prepare for difficult talks surrounding medical mistakes Effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism Ensuring staff safety when treating potentially violent patients Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach From shame to guilt to love Growth mindset approach to preparing trainees for medical error Healthcare staff wellbeing, burnout, and patient safety: a systematic review How to prevent burnout (maybe) IHI - building a clinician peer support program Implementation of a 'second victim' program in a pediatric hospital Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study Incivility, bullying, and workplace violence International children's hospitals' patient safety effort that is saving lives is expanding efforts to employee/staff safety International conference on physician health - 2016 presentations IOM - Action Collaborative on Clinician Well-Being and Resilience IOM - National Academy of Medicine launches 'Action Collaborative' to promote clinician well-being and combat burnout, depression, and suicide among health care workers Joint Commission - improving patient and worker safety - opportunities for synergy, collaboration and innovation Joint Commission - interview with Paul O'Neill Making it Safer Together (MiST) - caring for the carers Mayo Clinic - executive leadership and physician well-being. Nine organizational strategies to promote engagement and reduce burnout Medical error: the second victim MedStar Health HRO phase II: care for the caregiver MedStar Health - quality and patient safety videos - care for the caregiver programs Nationwide Children's - best outcomes in action: YOU Matter second victim program Nationwide Children's - Nationwide Children's hospital participating in international children's hospitals' patient safety effort that is saving lives and expanding efforts to employee/staff safety NPSF - just culture as a foundation for joy in work: the impact of leaders NPSF - three organizational strategies to reduce burnout and build engagement in health care NPSF - through the eyes of the workforce: creating joy, meaning, and safer health care NPSF - overlap between organizational contributions to burnout and workplace violence... is there overlap of solutions? Official critical care societies collaborative statement: burnout syndrome in critical care health care professionals: a call for action On the relationship between safety climate and occupational burnout in healthcare organizations Organizational framework to reduce professional burnout and bring back joy in practice OSHA worker safety in hospitals - caring for our caregivers Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses Patient safety improves when providers feel psychologically safe Patient safety and workplace bullying: an integrative review Paul O'Neill on protecting our healthcare workforce #NPSFLLI7 Paula Davis Laack - burnout Peer Support for Clinicians: A Programmatic Approach Physician burnout is a public health crisis: a message to our fellow health care CEOs Piece of my mind. Speak up. PIPSQC - who guards the guardians? Price of incivility Promoting safety through well-being: an experience in healthcare Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis Psychological responses, coping and supporting needs of healthcare professionals as second victims Quadruple Aim: care of the provider Qualitative study about the experiences of colleagues of health professionals involved in an adverse event Quotes from the Paul O'Neill podcast interview on patient safety Relationship between professional burnout and quality and safety in healthcare: a meta-analysis Respect: the foundation for quality care Rude providers jeopardize patient safety. So stop it Rudeness and medical team performance Scott three-tiered interventional model of second victim support Second victim: a review Surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study Triple Aim must turn into the Quadruple Aim. here’s why. Value Capture - opportunity: identifying and eliminating worker injuries Virginia Mason - respect for people: a building block for engaged staff, satisfied patients Unprofessional workplace conduct... defining and defusing it Why healthcare organizations must embrace the 'Quadruple Aim' Work systems analysis approach to understanding fatigue in hospital nurses Workplace factors associated with burnout of family physicians
Flow	Health Foundation - challenge and potential of whole system flow - improving the flow of people, information and resources across whole health and social care economies
General/Community Hospitals	See 'Adult Hospitals and the Care of Children'
Global Child Health	See 'Child Survival in Developing Countries'
Haematology/Oncology	2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015) CHA - Childhood Cancer & Blood Disorders Network CHA - for this children's hospital CEO, the fight against pediatric cancer is personal Chemotherapy safety standards: A pediatric perspective Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management Impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital Improving physician's hand over among oncology staff using standardized communication tool Interventions to improve oral chemotherapy safety and quality: a systematic review Just Bag It - NCCN campaign for safe Vincristine handling Making it Safer Together (MiST) - paediatric patient safety collaborative - haematology/oncology Performance of a trigger tool for identifying adverse events in oncology PIPSQC - unique patient safety challenges of children with cancer Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: A time series analysis Significant and sustained reduction in chemotherapy errors through improvement science Singularity University - Dr. Daniel Kraft WHO - early cancer diagnosis saves lives, cuts treatment costs
Hand Hygiene	AHA - HPOE - Children's Hospital Colorado - reliable hand hygiene Butterfly effect of hand hygiene on antibiotic resistance CDC - clean hands count CDC - hand hygiene in healthcare settings Clean Hands Save Lives CPSI - STOP! Clean Your Hands Day - tools and resources Effectiveness of a hospital-wide programme to improve compliance with hand hygiene Electronic hand-hygiene monitoring cuts MRSA rates by nearly half Hand washing stops infections, so why do health care workers skip it? How hospital workers solve patient-safety problems on their own Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance iScrub Lite Tell me how pleased you are with your workplace, and I will tell you how often you wash your hands WHO - Clean Care is Safer Care WHO hand-hygiene compliance strategy easy for health-care workers to practice WHO - patient safety - Geneva University Hospital WHO - save lives: clean your hands
Handoffs and Communication	As a critical behavior to improve quality and patient safety in health care: speaking up! Association between end-of-rotation resident transition in care and mortality among hospitalized patients Birmingham Children's - improving handovers in paediatric care (slides) Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care Challenging the status quo: focusing on patient safety and joy at work Changes in medical errors after implementation of a handoff program Conflict in a paediatric hospital: a prospective mixed-method study Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis Half-life of a printed handoff document Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture Handoffs: transitions of care for children in the emergency department Health Foundation - Safer Clinical Systems: Birmingham Children's Hospital High-reliability and the I-PASS communication tool Implementation of a modified bedside handoff for a postpartum unit Improving patient safety in handover from intensive care unit to general ward: a systematic review Improving physician's hand over among oncology staff using standardized communication tool Improving resident handoffs for children transitioning from the intensive care unit Information handoff and outcomes of critically ill patients transferred between hospitals Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program Introducing a new junior doctor electronic weekend handover on an orthopaedic ward I-PASS Handoff Study I-PASS, a mnemonic to standardize verbal handoffs Joint Commission - improving communication, reducing medical errors Joint Commission - Transitions of Care (ToC) portal Large-scale implementation of the I-PASS handover system at an academic medical centre Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes Model to support staff in raising their concerns Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment Nervecentre Software - clinical applications for mobile technology - clinical noting and ehandover New horizons in patient safety: understanding communication: case studies for physicians Paperless handover: are we ready? Patient Hand-Off iNitiation and Evaluation (PHONE) study: a randomized trial of patient handoff methods Patient handoffs: is cross cover or night shift better? PCORI - bringing I-PASS to the bedside: a communication bundle to improve patient safety and experience Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program PIPSQC - I-PASS in critical care Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings Quality of handoffs in community pharmacies Quality improvement approach to standardization and sustainability of the hand-off process Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle SaferHealthcare - Situation, Background, Assessment and Recommendation (SBAR) SickKids - shift-change handoff program recognized for improving patient safety through standardization of provider-to-provider communication Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies Standardization of inpatient handoff communication Standardization of postoperative transitions of care to the pediatric intensive care unit enhances efficiency and handover comprehensiveness Supporting quality improvement in paediatrics across an entire healthcare system Variation in printed handoff documents: results and recommendations from a multicenter needs assessment Year-end resident clinic handoffs: narrative review and recommendations for improvement
Health IT	Paediatric: AHRQ - children's electronic health record (EHR) format CHA - 6 ways children's hospitals are using mobile apps CHA - 25 biggest pediatric health care innovations in 25 years CHA - commentary: supplement health care technology with human interaction and communication Computerized provider order entry and patient safety Evaluating serial strategies for preventing wrong-patient orders in the NICU How medical tech gave a patient a massive overdose Innovative use of the electronic health record to support harm reduction efforts Leapfrog - pediatric CPOE evaluation tool National trends in safety performance of electronic health record systems in children's hospitals Restricted access Pediatric hospitals show wide gap in EHR safety performance Quality of care and information technology (special issue) Use of a health information exchange system in the emergency care of children Use of patient pictures and verification screens to reduce computerized provider order entry errors General: All CLEAR? Preparing for IT downtime Are informed policies in place to promote safe and usable EHRs? A cross-industry comparison Benefits of health information technology: a review of the recent literature shows predominantly positive results Characterizing the source of text in electronic health record progress notes Checking the lists: a systematic review of electronic checklist use in health care COACH - esafety guidelines: landmark patient safety resource Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors Datix patient safety software Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities Digital doctor: hope, hype, and harm at the dawn of medicine's computer age E-collection: safety and error prevention in health ECRI Institute - the partnership for health IT patient safety Effects of health information technology on patient outcomes: a systematic review Emerging from EHR purgatory - moving from process to outcomes Examining the copy and paste function in the use of electronic health records FDA - Computerized Prescriber Order Entry Medication Safety (CPOEMS) Health IT Safety Centre Roadmap HealthIT.gov - SAFER guides Health Level 7 (HL7) International - standards How to improve electronic health record usability and patient safety IHI - WIHI: digital transformation: how technology is helping (and hurting) health care Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis Impact of electronic medical records on hospital-acquired adverse safety events: differential effects between single-source and multiple-source systems Implications of electronic health record downtime: an analysis of patient safety event reports IOM - health IT and patient safety: building better systems for safer care IT's role in improving patient safety - where do we stand? Joint Commission - safe health IT saves lives Meaningful use of health information technology and declines in in-hospital adverse drug events National survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites NHS - the integrated digital care technology fund NPSF - organizational best practices for optimizing health IT safety ONC offers recommendations for safe, effective health IT use Pew analysis: despite ONC's EHR oversight, patient safety issues persist Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review Rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration Safety huddles to proactively identify and address electronic health record safety Study: clinicians copy and paste about half of text in EHR progress notes Towards a framework for managing risk associated with technology-induced error Unintended consequences of health IT: new problems and new solutions Vulnerabilities of computerized physician order entry systems: a qualitative study
Health Literacy	CDC - clear communication index CDC - learn about health literacy Communicating clearly about medicines: proceedings of a workshop - in brief IOM - health literacy: past, present, and future: workshop summary Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency NPSF - Ask Me 3: good questions for your good health NPSF - health literacy Pennsylvania Patient Safety Authority - health literacy and patient safety events Pennsylvania Patient Safety Authority - health literacy oral communication skills for clinicians Preventing vital health care information from being lost in translation Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites
High Reliability and HROs	Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice AHRQ PSNet - primers - high reliability Aiming higher to enhance professionalism - beyond accreditation and certification Applying the high reliability health care maturity model to assess hospital performance: a VA case study Are hospitals really serious about patient safety? 6 things we can learn from other industries Ascension Health - establishing a culture of high reliability (page 20) Ascension Health - high reliability organizations healing without harm by 2014 (slides) Building a high-reliability organization: one system's patient safety journey Building the road to high reliability Children's Hospitals' Solutions for Patient Safety (SPS) - network design & process Comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality Cooperative high reliability organization: approaching a zero-defect culture Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals Eliminating patient harm - in embracing the concept of high reliability, hospitals work to stamp out patient harm Eliminating preventable harm to patients and staff Five lessons healthcare leaders are learning from an unlikely source: nuclear power Five system barriers to achieving ultrasafe health care HealthCare Reliability Organizing (HCRO) - about us Health Foundation - high reliability organisations Health Foundation - using safety cases in industry and healthcare Healthcare Performance Improvement (HPI) High-reliability health care: getting there from here High reliability helps Connecticut hospital reduce safety errors by 80 percent High-reliability and the I-PASS communication tool High reliability organizations finding a home in Canada High reliability organizations: a healthcare handbook for patient safety & quality High Reliability Organizing (HRO) High reliability pediatric intensive care unit High reliability: what's the role of the patient, family, public, and community? HQI - HealthCare Reliability Organizing (HCRO) IHI - framework for safe, reliable, and effective care IHI - highly reliable hospitals: the work ahead IHI - reliable systems and processes IHI - stop wasting time on 100 percent reliability IHI: this way to patient safety Imperial College London - safer healthcare - approaches to safety: one size does not fit all Imperial College London - transforming patient safety: a sector-wide systems approach Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers International prize in resilient health care Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition Joint Commission - model differentiates hospitals' high reliability maturity levels Joint Commission - safety culture and high reliability: stages of organizational maturity Joint Commission Center for Transforming Healthcare - high reliability Joint Commission Center for Transforming Healthcare - high reliability - resources Joint Commission Center for Transforming Healthcare - Michigan is the second state to partner with the Joint Commission center for transforming healthcare on a statewide high reliability improvement effort Leading high-reliability organizations in healthcare Long and winding road toward greater quality and safety - Memorial Hermann and Virginia Mason health systems make big leaps in improving patient safety MedStar Health - quality and patient safety - quality & safety videos - an introduction to HRO tools MedStar Health - safety across the board: integrating just culture, high reliability and open, honest communication More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England? Next wave of hospital innovation to make patients safer NPSF - reliability at the sharp end of care Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement Organizational behavior: a brief overview and safety orientation Organizational learning framework for patient safety PICC 2016 - risky business: critical care - learning from high risk industries to improve quality and safety Re-examining high reliability: actively organising for safety Reliability engineering & system safety - resilience engineering (special issue) Resilient health care, volume 3: reconciling work-as-imagined and work-as-done RHLN - reliability leadership: examples from a paediatric intensive care unit and the riverside county EMS SaferHealthcare - high reliability topics Safety perceptions of health care leaders in 2 Canadian academic acute care centers Safety and reliability in pediatrics (special issue) Stories clinicians tell: achieving high reliability and improving patient safety Towards high-reliability organising in healthcare: a strategy for building organisational capacity UHN - Renewing UHN - Caring Safely
Hospital Acquired Conditions (HACs): - ADE - CAUTI - CLABSI - Falls - OB-AE - PIVIE - PU - SSI - Unplanned Extubations - VAP - VTE	CLABSI: Alder Hey Children's - introduction of a specialist paediatric vascular access team in an acute trust (slides) CHA - Childhood Cancer & Blood Disorders Network - CLABSI prevention for ambulatory patients CHA - PICU CLABSI collaborative Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & CLABSI webinars Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis Fifteen years after To Err is Human: a success story to learn from Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial Incorporating quality and safety values into a CLABSI simulation experience Making it Safer Together (MiST) - vascular access PICC 2016 - how to secure and maintain intravenous access in the PICU Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: A time series analysis Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-Year analysis Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections Unbundling the bundles: using apparent and systemic cause analysis to prevent health care-associated infection in pediatric intensive care units Zero tolerance for deadly hospital-acquired infections Paediatric: AHA - Children's Colorado and Nationwide Children's quality and safety journey (slides) Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections CEC - pediatric quality program Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions Children's National - reducing harm: impact of unplanned extubations (pages 10-14) Children's spin-off company eKare wins Washington Business Journal 2106 Innovation Award Impact of a pressure injury prevention bundle in the Solutions for Patient Safety Network Innovative use of the electronic health record to support harm reduction efforts Making it Safer Together (MiST) - paediatric patient safety collaborative - safety themes NHS - Children and Young People's Services (C&YPS) NHS Safety Thermometer NINJA system aims to reduce acute kidney injury in hospitalized kids nationwide OPENPediatrics - leading towards zero harm (webinar) Scottish Patient Safety Programme (SPSP) - Maternity & Children Quality Improvement Collaborative (MCQIC) Surgical site infection reduction by the solutions for patient safety hospital engagement network Sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury Unbundling the bundles: using apparent and systemic cause analysis to prevent health care–associated infection in pediatric intensive care units General: AHRQ - Comprehensive Unit-based Safety Program (CUSP) AHRQ - funding announcement for projects targeting the reduction of healthcare-associated infections AHRQ - healthcare-associated infections program AHRQ - patient safety measure tools & resources - patient safety tools & resources AHRQ - toolkit to reduce CAUTI and other HAIs in long-term care facilities Ambient Clinical Analytics - syndromic surveillance - ventilator-induced lung injury sniffer (VILI sniffer) American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update ANA - CAUTI prevention tool CDC - healthcare associated infections CEC - patient safety programs Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017 CIHI - 1 in 18 patients experiences harm in Canadian hospitals - hospital harm project FAQ CIHI - hospital harm project CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm CMS - Partnership for Patients (PfP) - Hospital Improvement Innovation Networks (HIINs) CMS - Partnership for Patients (PfP) - resources Commonwealth Fund - hospitals in rapid-paced quality improvement Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes Danish Safer Hospital Programme packages Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative HRET - Hospital Engagement Network (HEN) 2.0 - Partnership for Patients (PfP) education series HRET - Hospital Engagement Network (HEN) 2.0 - topics Hybrid methodology for modeling risk of adverse events in complex health-care settings Intentional rounding: a staff-led quality improvement intervention in the prevention of patient falls Joint Commission Center for Transforming Healthcare - targeted initiatives Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System Medicare failed to investigate suspicious infection cases from 96 hospitals MRSA rates dropped 87% in VA hospital ICUs Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach National implementation project to prevent catheter-associated urinary tract infection in nursing home residents NDNQI - pressure ulcer survey guide NHS - NHS Safety Thermometer PaSQ - patient safety and quality of care good practices Patient engagement with surgical site infection prevention: an expert panel perspective Patient Safety Movement - challenges & solutions Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project Proactive risk assessment of surgical site infections in ambulatory surgery centers SHEA - compendium of strategies to prevent healthcare-associated infections in acute care hospitals Systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes Tension between promoting mobility and preventing falls in the hospital Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events UHN - Caring Safely (slides) Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls Viewing Prevention of Catheter-Associated Urinary Tract Infection as a System: Using Systems Engineering and Human Factors Engineering in a Quality Improvement Project in an Academic Medical Center WHO - global guidelines on the prevention of surgical site infection WHO guidelines take aim at surgical infections, superbugs WHO - patient safety - implementing change Note: Hospital Acquired Conditions (HACs) include: adverse drug events (ADE); catheter-associated urinary tract infections (CAUTI); central line-associated blood stream infections (CLABSI); injuries from falls and immobility; obstetrical adverse events (OB-AE); peripheral intravenous infiltration and extravasations (PIVIE); pressure ulcers (PU); surgical site infections (SSI); unplanned extubations; ventilator-associated pneumonia (VAP); venous thromboembolism (VTE); and more.
Hospital Acquired Infections (HAIs)	See 'Hospital Acquired Conditions (HACs)'
Hospital at Night (HaN)	Birmingham Children's - improving handovers in paediatric care (slides) Nervecentre Software - clinical applications for mobile technology - Hospital at Night (HaN)
Hospital Design	Bad hospital design is making us sicker Healthier Hospitals Initiative (HHI)
Huddles	See 'Situation Awareness'
Human Factors	5 thoughts from an Eisenberg Patient Safety and Quality Award winner A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong AHRQ - making health care safer II: an updated critical analysis of the evidence for patient safety practices - chapter 31: human factors and ergonomics AHRQ - mistake-proofing the design of healthcare processes AHRQ PSNet - human factors engineering Applying human-centered design thinking to enhance safety in the OR Atrainability - human factors training for safe and effective teams Bad hospital design is making us sicker CHFG - 'how to' guide to human factors - top tips CHFG - resources CHFG - top 10 health technology hazards - ECRI institute CHFG - 'what good looks like' prompt cards - from a human factors perspective CPQI - patient safety - SEIPS tools CPQI - Systems Engineering Initiative for Patient Safety (SEIPS) Defining the role of social sciences in patient safety online (special issue) Dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation ECRI Institute - top 10 health technology hazards for 2017 ECRI out with 10 deadly healthcare technology hazards for 2017 Embedding Human Factors for NHS patient safety FDA - applying human factors and usability engineering to medical devices - February 19, 2016 Handbook of human factors and ergonomics in health care and patient safety, second edition Health Foundation - safer care: human factors for healthcare Healthcare Human Factors - projects Healthcare Human Factors - target zero for patient safety Healthcare Human Factors - work HSE - Human Factors Human factors and ergonomics in manufacturing & service industries: patient safety (special issue) Human factors and ergonomics as a patient safety practice Human factors and ergonomics in practice - improving system performance and wellbeing in the real world Human factors and ergonomics and quality improvement science: integrating approaches for safety in healthcare Human Factors and Ergonomics Society (HFES) - health care symposia Human Factors and Ergonomics Society (HFES) - health care technical group of HFES Human factors-focused reporting system for improving care quality and safety in hospital wards Human factors in healthcare: welcome progress, but still scratching the surface Human factors science: brief history and applications to healthcare HumanEra - projects Humanistic systems Improving infusion pump safety through usability testing Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature Inpatient notes: human factors engineering and inpatient care - new ways to solve old problems Interview with Pascale Carayon Joint Commission Big Book of Checklists MedStar Health - human factors and patient safety MedStar Health - safety across the board: integrating just culture, high reliability and open, honest communication More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England? National Center for Human Factors Engineering in Health Care - research New focus on hospital errors aims to correct problems NHS - Human factors and patient safety culture Operational failures detected by frontline acute care nurses Patient safety: the role of human factors and systems engineering PIPSQC - systems thinking and the paediatric provider (slides) Resilient health care, volume 3: reconciling work-as-imagined and work-as-done Safety differently - Steven Shorrock Safety differently: human factors for a new era Sidney Dekker - safety differently - talks Systems Engineering Initiative for Patient Safety (SEIPS) - short course Utilizing a human factors nursing worksystem improvement framework to increase nurses' time at the bedside and enhance safety WHO - patient safety - human factors tools Work systems analysis approach to understanding fatigue in hospital nurses
Journals	AHRQ PSNet - pediatrics CHA - Children's Hospitals Today - patient safety CHA - Children's Hospitals Today - quality improvement Current Treatment Options in Pediatrics - topical collection on patient safety Pediatric Clinics of North America - quality of care and information technology Pediatric Clinics of North America - safety and reliability in pediatrics Pediatric Quality & Safety (PQS) Quality and Safety in Health Care (special issue)
Junior Doctors	Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment CHA - pediatric learning solutions - online training to foundational clinical information Chief of residents for quality improvement and patient safety: a recipe for a new role in graduate medical education DAPS (Doctors Advancing Patient Safety) Global Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis Dr. Toolbox - collaborative local knowledge resource for professional healthcare communities Growth mindset approach to preparing trainees for medical error IHI Open School - online courses in patient safety and improvement capability Increasing resident autonomy without compromising patient safety Is the "July Effect" real? Pediatric trainee reported medical errors and adverse events Making residents part of the safety culture: improving error reporting and reducing harms Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature 'See one, sim one, do one' - a national pre-internship boot-camp to ensure a safer 'student to doctor' transition You can't blame the wreck on the train
Leadership	Boards can be safety champions - trustees play a critical role in overseeing patient safety Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers Center for Patient Safety - leadership, louder than words: C-suite ambassadors of patient safety Closing the gap and raising the bar: assessing board competency in quality and safety Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine Do hospital boards matter for better, safer, patient care? CMS - Partnership for Patients (PfP) - leadership How much should hospital trustees know about patient safety? Joint Commission - essential role of leadership in developing a safety culture Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition Knowing, and doing: closing the gaps in board leadership for improvement of quality and safety NHS Improvement - developing people - improving care - a national framework for action on improvement and leadership development in NHS-funded services NPSF - leading a culture of safety: a blueprint for success Patient safety efforts need engaged leaders Patient safety and leadership: do you walk the walk? PIPSQC - leadership and preoccupation with failure Safety perceptions of health care leaders in 2 Canadian academic acute care centers WHO - global experts’ consultation for the development of the leaders’ guide
Malpractice	2% of physicians accountable for half of malpractice reports Association between state medical malpractice environment and postoperative outcomes in the United States Association of unsolicited patient observations with the quality of a surgeon's care CMPA - diagnostic tips - reducing medical-legal difficulties Detection, analysis, and significance of physician clustering in medical malpractice lawsuit payouts Doctor's Company - pediatrics resources Doctors could admit to mistakes without facing liability in court under proposed legislation Fewer medical malpractice lawsuits succeed, but payouts are up Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis HPOE - progress at the intersection of patient safety and medical liability Impact of medical errors and malpractice on health economics, quality, and patient safety Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States Medical Malpractice Center - pediatric malpractice NPSF - patient complaints and post-operative complications Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014 Relationship between state malpractice environment and quality of health care in the United States Two words can soothe patients who have been harmed: we're sorry Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications
Medical Devices	AAP - safe and effective drugs and medical devices for children CAPHC - implementing the ENFit standards: preparing for the impact on clinical practice ECRI Institute - browse topics ECRI Institute - top 10 health technology hazards for 2017 Emergency department visits for medical device-associated adverse events among children FDA - applying human factors and usability engineering to medical devices - February 19, 2016 FDA - pediatric medical devices FDA - reducing risks associated with medical device misconnections FDA working to ensure the safety of medical devices used in the pediatric population Implementing smart infusion pumps with dose-error reduction software: real-world experiences Improper device cleaning may be leading to infections or broken devices Improving infusion pump safety through usability testing ISMP - ENFit enteral devices are on their way... Important safety considerations for hospitals Making it Safer Together (MiST) - safety alert: is ENFit safe for small children & neonates? Mind the gap & why 'Ruby's Rule' won't work National Pediatric Readiness Project (Peds Ready) - guidelines for equipment, supplies, and medications for the care of pediatric patients in the ED NHS England - preventing medical device incidents IOM - safe medical devices for children Pediatric devices and adverse events from a to z: understanding the benefits and risks from a US FDA perspective Premier - tubing misconnections - resources Prevalence and nature of adverse medical device events in hospitalized children "We can't get along without each other": qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety
Medical Emergency Team (MET)	See 'Rapid Response Team (RRT)'
Medical Errors	See 'Adverse Event Detection'
Medication Safety	Assessment: CEC - Medication Safety Self Assessment Program (MSSA) Bar Code Medication Administration (BCMA): Comparison of medication safety systems in critical access hospitals: combined analysis of two studies Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework Effect of barcode-assisted medication administration on emergency department medication errors Effects of bar-coding technology on medication errors: a systematic literature review Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events Improved supply chain in Canadian health system can save lives NPSF - medication barcode optimization OhioHealth improves patient safety with processes and advanced technologies Pediatric medication administration errors and workflow following implementation of a bar code medication administration system WIN - visibility: the new value proposition for health systems (slides) WIN - visibility: the new value proposition for health systems - executive summary Computerized Physician Order Entry (CPOE): AHRQ - children's electronic health record (EHR) format Analysis of variations in the display of drug names in computerized prescriber-order-entry systems Assessing frequency and risk of weight entry errors in pediatrics Automated detection of look-alike/sound-alike medication errors Bainbridge Health - makes infusion pump management easier and "smarter" CHA - saving lives and reducing medication errors with data Clinical decision support for drug related events: moving towards better prevention Clinical reasoning in the context of active decision support during medication prescribing CPOE and patient safety CPOE-related patient safety reports: analysis of 2522 medication errors Digital doctor: hope, hype, and harm at the dawn of medicine's computer age ECRI Institute - the partnership for health IT patient safety EHR-related medication errors in two ICUs Electronically generated medication administration and electronic medication administration records for the prevention of medication transcription errors: review of clinical effectiveness and safety Evaluating serial strategies for preventing wrong-patient orders in the NICU Evaluation of medication-related clinical decision support alert overrides in the intensive care unit Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study FDA - Computerized Prescriber Order Entry Medication Safety (CPOEMS) Health IT Safety Center Roadmap HealthIT.gov - SAFER guides High-priority drug-drug interactions for use in EHRs Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture Incorporating indications into medication ordering - time to enter the age of reason Joint Commission - safe health IT saves lives Leapfrog - pediatric CPOE evaluation tool Learning from errors: analysis of medication order voiding in CPOE systems Looking for safety insights in medication order changes Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations National trends in safety performance of EHR systems in children's hospitals ONC offers recommendations for safe, effective health IT use Optimization of drug-drug interaction alert rules in a pediatric hospital's EHR using a visual analytics dashboard Ordering interruptions in a tertiary care center: a prospective observational study Pablo Garcia case study (full story): How medical tech gave a patient a massive overdose Pablo Garcia case study (Part 5): How to make hospital tech much, much safer - We identified the root causes of Pablo Garcia's 39-fold overdose?- and ways to avoid them next time Pediatric hospitals show wide gap in EHR safety performance Pennsylvania Patient Safety Authority - medication errors attributed to health information technology Prescription errors related to the use of computerized provider order-entry system for pediatric patients Responsible e-prescribing needs e-discontinuation Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine Screening for medication errors using an outlier detection system Systematic review of the types and causes of prescribing errors generated from using CPOE systems in primary and secondary care Use of patient pictures and verification screens to reduce CPOE errors Vulnerabilities of CPOE systems: a qualitative study Emergency Medications: Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial Medication errors in the management of anaphylaxis in a pediatric emergency department Meds IQ - emergency bolus and infusion calculators - New Zealand Meds IQ - emergency drug dose calculator Monash Children's - pediatric emergency medication book National Pediatric Readiness Project (Peds Ready) - guidelines for equipment, supplies, and medications for the care of pediatric patients in the ED National Pediatric Readiness Project (Peds Ready) - key points on medication errors Pediatric Emergency Medication Book - book review Pediatric prehospital medication dosing errors: a mixed-methods study Pediatric prehospital medication dosing errors: a national survey of paramedics PIPSQC - keeping kids safe during resuscitation and critical illness Quality improvement intervention reduces the time to administration of stat medications Errors - Inpatient: Alarming reality of medication error: a patient case and review of Pennsylvania and national data Economic impact of medication error: a systematic review Elimination of emergency department medication errors due to estimated weights Medication safety in neonatal care: a review of medication errors among neonates PA Patient Safety Advisory - Medication errors affecting pediatric patients: unique challenges for this special population Sick children face potentially deadly danger: medication errors Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital Errors - Outpatient: All consumer medication information is not created equal: implications for medication safety Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database Carers' medication administration errors in the domiciliary setting: a systematic review CDC - PROTECT initiative: advancing children's medication safety CDC - UpandAway.org Communicating clearly about medicines: proceedings of a workshop - in brief Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions Economic impact of medication error: a systematic review Fate of pediatric prescriptions in community pharmacies Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit Medication errors in outpatient pediatrics Misuse of pediatric medications and parent-physician communication: an interactive voice response intervention Out-of-hospital medication errors among young children in the United States, 2002-2012 Patient-centered prescription drug label to promote appropriate medication use and adherence Pediatric adverse drug events in the outpatient setting: an 11-year national analysis US emergency department visits for outpatient adverse drug events, 2013–2014 High-Alert Drugs: 2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology Association of medication errors with drug classifications, clinical units, and consequence of errors: are they related? Automated detection of look-alike/sound-alike medication errors Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015) Challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations Chemotherapy safety standards: a pediatric perspective Evaluating the potential severity of look-alike, sound-alike drug substitution errors in children ISMP - ISMP updates its list of drug names with tall man letters Just Bag It - NCCN campaign for safe Vincristine handling Medication errors associated with transition from insulin pens to insulin vials New safety risks detected in one-third of FDA-approved drugs PA Patient Safety Authority - analysis of reported drug interactions: a recipe for harm to patients Preventing high-alert medication errors in hospital patients Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet Significant and sustained reduction in chemotherapy errors through improvement science 'Smart pills' help doctors monitor patients from a distance Huddle: Meds IQ - DRUG-gle (Druggle) - medication-focused safety 'huddle' Medication Administration: Differentiating between detrimental and beneficial interruptions: a mixed-methods study Double checking the administration of medicines: what is the evidence? a systematic review Drug administration errors in hospital inpatients: a systematic review Comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study Electronically generated medication administration and electronic medication administration records for the prevention of medication transcription errors: review of clinical effectiveness and safety Implementing a distraction-free practice with the Red Zone Medication Safety Initiative Interruption handling strategies during paediatric medication administration Interruptions and medication administration in critical care Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis Meds IQ - new content on Meds IQ launching this autumn - medicines administration! Meds IQ - safe treatment and administration of medicines in paediatrics (STAMP) Meds IQ - safe treatment and administration of medicines in paediatrics (STAMP) - webinar recording Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting NPSF - National Patient Safety Foundation DAISY award for extraordinary nurses 2017 honorees announced Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices Nursing interruptions in a trauma intensive care unit: a prospective observational study Patients at risk from 'nested interruptions' in nursing tasks, human factors paper reports Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode Qualitative, exploratory study of nurses' decision-making when interrupted during medication administration within the paediatric intensive care unit Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era Relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study Teaching students to administer medications safely Traditions of research into interruptions in healthcare: a conceptual review Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare Using human factors design principles and industrial engineering methods to improve accuracy and speed of drug selection with medication trays Utilizing a human factors nursing worksystem improvement framework to increase nurses' time at the bedside and enhance safety Medication Reconciliation (MedRec): Beyond medication reconciliation: the correct medication list CPSI - 5 questions to ask about your medications Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions? Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge High 5s initiative: implementation of medication reconciliation in France a 5 years experimentation Holland Bloorview - implementation of medication reconciliation in a pediatric ambulatory care setting (slides) Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review electronically prepopulated medication reconciliation forms may actually adversely impact medication safety Insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs Measuring to improve medication reconciliation in a large subspecialty outpatient practice Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care Medication reconciliation process and classification of discrepancies: a systematic review Medication reconciliation: the role of the pharmacy technician MediStori - paper based personal health organizer Meds IQ - medicines reconciliation in children Nurse-pharmacist collaboration on medication reconciliation prevents potential harm Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis PSQH - medication reconciliation: improve compliance across healthcare settings SHM - MARQUIS - medication reconciliation implementation toolkit Value of the pharmacist in the medication reconciliation process WHO - High 5s Project - medication reconciliation implementation guide Operating Room Medications: Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study Medication safety in the operating room: literature and expert-based recommendations Opioids: APSF - monitoring for opioid-induced ventilatory impairment (OIVI) Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis CAPHC - June 12 ministerial opioid roundtable CAPHC - paediatric opioid safety resource kit CHA - rate of toddlers hospitalized from opioid poisoning on the rise Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015 FDA - safe use initiative Guideline for opioid therapy and chronic noncancer pain Human factors approach to evaluating intravenous morphine administration in a paediatric surgical unit iDoseCheck - morphine double check iDoseCheck - preventing wrong dose morphine errors - testing the iDoseCheck: a tool to enhance inter-professional communication and care planning (slides) Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score? ISMP - a national collaborative: advancing medication safety in paediatrics NPSF - surveillance monitoring for all Opioid medication errors in pediatric practice: four years' experience of voluntary safety reporting Opioid prescribing and potential overdose errors among children 0 to 36 months old Overdose risk in young children of women prescribed opioids Potential acetaminophen and opioid overdoses in young children prescribed combination acetaminophen/opioid preparations PPAHS - 5 keys to reducing harms from opioids: Physician-Patient Alliance for Health & Safety releases podcast with ECRI Institute PPAHS - opioid safety PPAHS - patients on opioids should be monitored for respiratory compromise 24×7 Prescription opioid exposures among children and adolescents in the United States: 2000-2015 Prescriptions may hold clues to who gets hooked on opioids, study says SIDM - opioid crisis: can improving diagnosis help solve the problem? Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analgesia in a UK paediatric hospital Studies raise questions about why young mothers are being prescribed opioids Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015 Pharmacists: ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education - 2015 Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study Could it be done safely? Pharmacists views on safety and clinical outcomes from the introduction of an advanced role for technicians Death due to pharmacy compounding error reinforces need for safety focus Do the math: time for pharmacists in the ED Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study) Medication safety systems and the important role of pharmacists Pharmacy automation system PillPick helps hospitals eliminate medication errors Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance Prescribing: Analysis of medication prescribing errors in critically ill children Assessing frequency and risk of weight entry errors in pediatrics Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review Effect of prescriber education on medication-related patient harm in the hospital: a systematic review Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective Is an indication-based prescribing system in our future? ISMP - despite technology, verbal orders persist, read back is not widespread, and errors continue Making it Safer Together (MiST) - electronic prescribing and administration Meds IQ - Paediatric SCRIPT - safe and effective prescribing for children Ordering interruptions in a tertiary care center: a prospective observational study PA Patient Safety Advisory - prescribing errors that cause harm PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique Prescription errors related to the use of computerized provider order-entry system for pediatric patients Proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation Reducing adverse drug events - the need to rethink outpatient prescribing Responsible e-prescribing needs e-discontinuation Priority Areas: CDC - PROTECT initiative: advancing children's medication safety CEC - Medication Safety Self Assessment Program (MSSA) Children's Hospitals' Solutions for Patient Safety (SPS) - recommended bundles - adverse drug events (ADE) CMS - Partnership for Patients (PfP) - adverse drug event priority areas for pediatric patients (slides) CMS - Partnership for Patients (PfP) - adverse drug event priority areas for pediatric patients (notes) CMS - Partnership for Patients (PfP) - Dale Ann Micalizzi - an uphill climb leading to patient safety IOM - safe and effective medicines for children Interventions to reduce pediatric medication errors: a systematic review ISMP - getting closer to the bull’s eye: 2014-2015 targeted medication safety best practices (follow-up survey results) ISMP - a national collaborative: advancing medication safety in paediatrics ISMP - results of survey on pediatric medication (part 1) ISMP - results of survey on pediatric medication (part 2) ISMP - survey on implementation of the 2016-2017 targeted medication safety best practices for hospitals ISMP - two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes Medication governance: preventing errors and promoting patient safety Medication safety in the neonatal intensive care unit: big measures for our smallest patients Meds IQ - sharing QI resources for paediatric medication safety Meds IQ - champions network Patient Safety Movement - challenges & solutions - pediatric adverse drug events Pediatric medication safety in adult community hospital settings: a glimpse into nationwide practice PIPSQC - from innovation to dissemination: Meds IQ, a new platform for paediatric medicines safety QI Prevention of medication errors in the pediatric inpatient setting Report of the announced inspection of medication safety at the Midland Regional Hospital Tullamore, County Offaly SPS - adverse drug event (ADE) prevention roadmap Three simple rules to improve medication safety WHO - medication without harm: WHO's third global patient safety challenge WHO - WHO global patient safety challenge - medication safety WHO - WHO launches global effort to halve medication-related errors in 5 years Reporting: Adverse drug event reporting systems: a systematic review Learning from the design, development and implementation of the Medication Safety Thermometer National Coordinating Council for Medication Error Reporting and Prevention creates an analysis tool for adverse drug events National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) NHS Safety Thermometer - medication safety thermometer Smart Infusion Pumps: Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital Bainbridge Health - makes infusion pump management easier and "smarter" CHA - saving lives and reducing medication errors with data Changing smart pump vendors: lessons learned Dangerous infusion errors top ECRI Institute's annual health technology hazards list Frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study Implementing smart infusion pumps with dose-error reduction software: real-world experiences Improving infusion pump safety through usability testing Infusion medication error reduction by two-person verification: a quality improvement initiative Role of 'smart' infusion pumps in patient safety Standardisation - Infusions: ASHP - IV adult continuous infusions ASHP - Standardize 4 Safety - first national effort to standardize medication concentrations Making it Safer Together (MiST) - infusion standardization - September 2016 update Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors Meds IQ - infusion standardisation NSW Health - standards for paediatric IV fluids: NSW Health (2nd edition) Risk factors for i.v. compounding errors when using an automated workflow management system Royal Children's - paediatric injectable guidelines Safe implementation of standard concentration infusions in paediatric intensive care Standard concentration infusions in paediatric intensive care: the clinical approach Standardize 4 Safety initiative releases final IV recommendations for medication safety Standardizing concentrations of adult drug infusions in Indiana Standardisation - Oral Liquids: FDA - Safe Use Initiative - unintentional medication overdoses in children Liquid medication errors and dosing tools: a randomized controlled experiment Michigan Pediatric Safety Collaboration to Standardize Compounded Oral Liquids Standardization of compounded oral liquids for pediatric patients in Michigan Tubing Misconnections: AAP - safe and effective drugs and medical devices for children ASPEN safe practices for enteral nutrition therapy CAPHC - implementing the ENFit standards: preparing for the impact on clinical practice FDA - pediatric medical devices FDA - reducing risks associated with medical device misconnections FDA working to ensure the safety of medical devices used in the pediatric population ISMP - accidental IV infusion of heparinized irrigation in the OR ISMP - ENFit enteral devices are on their way... Important safety considerations for hospitals Making it Safer Together (MiST) - safety alert: is ENFit safe for small children & neonates? Mind the gap & why 'Ruby's Rule' won't work Pediatric devices and adverse events from a to z: understanding the benefits and risks from a US FDA perspective Premier - tubing misconnections - resources Prevalence and nature of adverse medical device events in hospitalized children Global: Institute for Safe Medication Practices (ISMP) International Medication Safety Network (IMSN) Medication safety for children in China Medication Safety Officers Society (MSOS) WHO - essential medicines for children - publications WHO - medication without harm: WHO's third global patient safety challenge WHO - WHO global patient safety challenge - medication safety
Mental Health	CAPHC - addressing the adolescent depression challenge Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports MindEd Pediatric and adolescent mental health emergencies in the emergency medical services system Scottish Patient Safety Programme (SPSP) - mental health Teenmentalhealth.org
Mislabeled Specimens	Blood bank safety practices - mislabeled samples and wrong blood in tube - a Q-Probes analysis of 122 clinical laboratories Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions Dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation Final Check - reason for a 90+% reduction in the number of mislabeled blood specimens Getting it right for patient safety: specimen collection process improvement from operating room to pathology Managing the patient identification crisis in healthcare and laboratory medicine Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module Surgical specimen management: a descriptive study of 648 adverse events and near misses
Morbidty and Mortality (M&M) Rounds	CPS - standardization of child & youth death review Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study Envisioning the future morbidity and mortality conference: a vehicle for systems change Implementation of a structured hospital-wide morbidity and mortality rounds model Investigating avoidable patient deaths Learning, candour and accountability. A review of the way NHS trusts review and investigate the deaths of patients in England Medical morbidity and mortality conferences: past, present and future Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? New programme aims to standardise hospital death reviews Processes for identifying and reviewing adverse events and near misses at an academic medical center Role of morbidity and mortality rounds in medical education: a scoping review Quality gaps identified through mortality review Standardization of case reviews (morbidity and mortality rounds) promotes patient safety
National Patient Safety Board	CHFG - healthcare safety investigation branch - expert advisory group report CHFG - learning from failure: the need for independent safety investigation in healthcare Healthcare needs an NTSB-like agency National patient safety board necessary to prevent patient deaths NTSB for health care: learning from innovation: debate and innovate or capitulate Patient-safety advocates issue call for regulation Patient safety advocates urge the creation of a national patient safety board to fight medical errors Patient safety leaders propose ‘NTSB for healthcare’ Why congress needs to create a national patient safety board Would an NTSB approach succeed in healthcare?
Neonatal Intensive Care Unit (NICU)	See 'Neonatal-Perinatal'
Neonatal-Perinatal	BAPM - Newborn Early Warning Trigger and Track (NEWTT) 'Busy day' effect on perinatal complications of delivery on weekends Canadian Neonatal Network (CNN) CAPHC - CIHR-IHDCYH's preterm birth initiative: investing in preterm birth and perinatal health care research Case for quality improvement in the neonatal intensive care unit CDC - perinatal quality collaboratives CHA - strategies to care for babies born drug dependent Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions Comparing NICU teamwork and safety climate across two commonly used survey instruments Decreasing malpractice claims by reducing preventable perinatal harm How communication among members of the health care team affects maternal morbidity and mortality IHI - Perinatal Improvement Community Implementation of a modified bedside handoff for a postpartum unit Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist? Last person you'd expect to die in childbirth Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit Medication safety in neonatal care: a review of medication errors among neonates Medication safety in the neonatal intensive care unit: big measures for our smallest patients National Perinatal Information Center - quality improvement/patient safety NHS England - Saving Babies' Lives Care Bundle NICHQ - Collaborative Improvement and Innovation Network (COIIN) to Reduce Infant Mortality NPSF - reducing MRSA infections in the neonatal ICU Ohio Perinatal Quality Collaborative Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative Premier Perinatal Safety Initiative Progress at the intersection of patient safety and medical liability (special issue) RCOG - Each Baby Counts Safety interventions on the labor and delivery unit Second Victim: a review Temporary tattoo that brings hospital care to the home Tools and methods for quality improvement and patient safety in perinatal care Transforming maternity care - maternal and perinatal care quality collaboratives UCSF - Preterm Birth Initiative (PTBi) Vermont Oxford Network (VON) - improving care for infants and their families WHO - Collaborating Center for Training and Research in Newborn Care
Never Events	See 'Sentinel Events'
Opioids	2017 Canadian guidelines for opioids for chronic non cancer pain Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs APSF - monitoring for opioid-induced ventilatory impairment (OIVI) Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis CAPHC - June 12 ministerial opioid roundtable CAPHC - paediatric opioid safety resource kit CHA - rate of toddlers hospitalized from opioid poisoning on the rise CHA - strategies to care for babies born drug dependent Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015 Declines in opioid prescribing after a private insurer policy change - Massachusetts, 2011 - 2015 Development and applications of the Veterans health administration's stratification tool for opioid risk mitigation (STORM) to improve opioid safety and prevent overdose and suicide Emergency room doctors may impact patients' opioid use Ending the opioid epidemic - a call to action FDA - safe use initiative Guideline for opioid therapy and chronic noncancer pain Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration Human factors approach to evaluating intravenous morphine administration in a paediatric surgical unit iDoseCheck - morphine double check iDoseCheck - preventing pediatric medication errors - testing the iDoseCheck iDoseCheck - preventing wrong dose morphine errors - testing the iDoseCheck: a tool to enhance inter-professional communication and care planning (slides) Impact of the opioid safety initiative on opioid-related prescribing in veterans Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score? ISMP - a national collaborative: advancing medication safety in paediatrics Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates Medication sharing, storage, and disposal practices for opioid medications among US adults National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012 New persistent opioid use after minor and major surgical procedures in US adults NPSF - surveillance monitoring for all Opioid medication errors in pediatric practice: four years’ experience of voluntary safety reporting Opioid overdoses among kids, teens have nearly tripled in recent years Opioid-prescribing patterns of emergency physicians and risk of long-term use Opioid prescribing and potential overdose errors among children 0 to 36 months old Opioid-related inpatient stays and emergency department visits by state, 2009-2014 Opioids for pain management in older adults: strategies for safe prescribing Overdose risk in young children of women prescribed opioids Pain management and prescription opioid-related harms: exploring the state of the evidence: proceedings of a workshop - in brief Physicians take steps to address opioid overdose epidemic Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey Potential acetaminophen and opioid overdoses in young children prescribed combination acetaminophen/opioid preparations PPAHS - 5 Keys to Reducing Harms from Opioids: Physician-Patient Alliance for Health & Safety Releases Podcast with ECRI Institute PPAHS - opioid safety PPAHS - patients on opioids should be monitored for respiratory compromise 24×7 Predictors of in-hospital postoperative opioid overdose after major elective operations: a nationally representative cohort study Prescription drug monitoring programs: evidence-based practices to optimize prescriber use Prescription opioid exposures among children and adolescents in the United States: 2000-2015 Prescriptions may hold clues to who gets hooked on opioids, study says SIDM - opioid crisis: can improving diagnosis help solve the problem? Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analgesia in a UK paediatric hospital Studies raise questions about why young mothers are being prescribed opioids Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976-2015 Turn the Tide Rx - surgeon general's call to end opioid crisis U of T - safe opioid prescribing skills webinar series US Department of Veterans Affairs - VHA pain management - opioid safety initiative (OSI)
Paediatric Early Warning System (PEWS)	Electronic: Birmingham Children's - RAPID (Real-Time Adaptive and Predictive Indicator of Deterioration) Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children Impact of introducing an electronic physiological surveillance system on hospital mortality Nervecentre Software - clinical applications for mobile technology - electronic observations (e-PEWS) Nervecentre Software - top 5 reasons trusts chose Nervecentre for electronic observations NHS England - electronic PEWS NHS England - integrated digital care record - success story: safer hospitals, safer wards technology fund (Nottingham University Hospitals) NUH - Using mobile technology to transform communication and safety - electronic 'eObservations and eHandover' Real-time risk prediction on the wards: a feasibility study Emergency Department: CHA - 20 second sepsis screen (slides) Identifying high-risk children in the emergency department Scoring systems in paediatric emergency care: panacea or paper exercise? Australia: ACSQHC - observation charts for paediatric and maternity settings ACSQHC - recognising and responding to clinical deterioration - guide to implementation of the national consensus statement 'Between the flags': implementing a rapid response system at scale CEC - Pediatric Quality Program - Between the Flags (BtF) Children's Hospital at Westmead - lessons from medical emergency teams in Australia (slides) Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis Improving the recognition of, and response to in-hospital sepsis Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios Royal Children's - escalation of care flowchart Royal Children's - Victorian Children's Tool for Observation and Response (ViCTOR) Victorian Children's Tool for Observation and Response (ViCTOR) Europe: BAPM - Newborn Early Warning Trigger and Track (NEWTT) HSE - Irish Paediatric Early Warning System (PEWS) ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients MiST - paediatric early warning systems (PEWS) NCEC national clinical guidelines - clinical deterioration - paediatric early warning system (PEWS) NHS - Children and Young People's Services (C&YPS) Safety Thermometer - deterioration NHS England - exploring a national paediatric early warning system (PEWS) NHS England - PEWS charts NHS England - Respond to Ailing Child Tool (Re-ACT) NUH - Recognise and Rescue: a hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals NHS Trust NUH - Recognise and Rescue - improving the care of the deteriorating pediatric patient NUH - Recognise and Rescue praised by NHS England leaders NUH - Recognise and Rescue programme: improving patient safety Nurses' 'worry' as predictor of deteriorating surgical ward patients: a prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score Optimizing patient safety for paediatric patients in 5 Dutch general hospitals by introducing PEWS within an (inter)national exchange collaborative network Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review Paediatric Early Warning Systems: myths and muses PaSQ - paediatric early warning scores (PEWS) PIPSQC - don't just stand there - #REACT! REACT - the Respond to Ailing Children Tool PIPSQC - Irish Paediatric Early Warning System (PEWS) PUMA Paediatric early warning systems: Utility and Mortality Avoidance RCPCH - safe system framework for children at risk of deterioration RCPCH - Situation Awareness for Everyone (S.A.F.E) Spotting the Sick Child SPSP - paediatric care - paediatric early warning score (PEWS) charts SPSP - paediatric care - Paediatric Sepsis 6 SPSP - paediatric care - PEWS as a system SPSP - paediatric care - PEWS as a system - webex Supporting quality improvement in paediatrics across an entire healthcare system Systematic literature review to support the development of a national clinical guideline - paediatric early warning system (PEWS) UK Sepsis Trust - clinical toolkits - acute hospital-inpatients Validation of National Early Warning Score in the prehospital setting What impact did a paediatric early warning system have on emergency admissions to the paediatric intensive care unit? an observational cohort study North America: Bedside Clinical Systems (BCS) - BedsidePEWS - news Bedside Clinical Systems (BCS) - BedsidePEWS - product Cincinnati Children's - emergency codes outside the ICU Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: root cause analysis of unplanned ICU admissions Empowered Patient Coalition - Pediatric Warning Signs and Symptoms of Flu-like Illness Errors, omissions, and outliers in hourly vital signs measurements in intensive care Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial Finding patients before they crash: the next major opportunity to improve patient safety Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events Model can ID patients at risk for serious safety events Multicenter collaborative approach to reducing pediatric codes outside the ICU NPSF - surveillance monitoring for all Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides) South America: Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital
Paediatric Intensive Care Unit (PICU)	See 'Critical Care'
Pain	CAPHC - acute procedural pain: paediatric recommendations and implementation toolkits CAPHC - paediatric pain CAPHC - practice change: it doesn't have to be painful! Centre for Pediatric Pain Research - resources for health professionals Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals It Doesn't Have to Hurt - proven pain control for children Neonatal pain: what's age got to do with it? NHS - Children and Young People's Services (C&YPS) Safety Thermometer Pain in hospitalized children: effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes SickKids - pain centre Systematic review of the effects of repeated painful procedures in infants: is there a potential to mitigate future pain responsivity?
Patient and Family Engagement	Bedside Nursing Handover: AHRQ - nurse bedside shift report AHRQ Health Care Innovations Exchange - standardized shift-change process optimizes time for transfer of patient care responsibility, leads to high levels of nurse and patient satisfaction CHA - partnering with children and families to achieve bedside nursing shift-handover Cincinnati Children's - increasing patient satisfaction by moving nursing shift report to the bedside Nurse Knowledge Exchange Plus: human-centered implementation for spread and sustainability PCORI - bringing I-PASS to the bedside: a communication bundle to improve patient safety and experience SickKids - partnering with children and families to achieve bedside nursing shift-handover (slides) Family Activated RRT: CHEO - CHEO's SPOT Team and Patient Safety Ambassadors program Developing and evaluating the success of a family activated medical emergency team: a quality improvement report Family initiated escalation of care for the deteriorating patient in hospital: Family centred care or just "box ticking" Impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review Josie King Foundation - Condition Help (Condition H) Queensland Health - Ryan's Rule - consumer/family escalation process Family-Centered Rounds: Cincinnati Children's - implementing patient- and family-centered rounds Family-centered rounds checklist, family engagement, and patient safety: a randomized trial PIPSQC - ward rounds: ideas for making them better Reporting: Barriers and facilitators of adverse event reporting by adolescent patients and their families BC Children's - establishing a pediatric family-initiated safety reporting program (slides) BC Children's - patient's view: seeing safety through the eyes of families at BC Children’s Hospital BC Children's - what a family perspective teaches about adverse events in the pediatric setting (slides) Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report Families as partners in hospital error and adverse event surveillance Implementation and evaluation of a prototype consumer reporting system for patient safety events Parent-reported errors and adverse events in hospitalized children Patient feedback reporting tool for OpenNotes: implications for patient–clinician safety and quality partnerships Patient reported approach to identify medical errors and improve patient safety in the emergency department Patient reporting and action for a safe environment (PRASE) intervention: a feasibility study PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety Using an inpatient portal to engage families in pediatric hospital care Shared Decision Making: Citizens for Patient Safety - shared decision making Doctor's Company - are decisions shared? IHI/NPSF - webcast: shared decision making and patient safety: making the connections Paediatric: Ask Me to Explain Campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department But I told you she was ill! the role of families in preventing avoidable harm in children CAPHC - 'Passport' helps parents plan move from hospital to home CHA - discussing quality with patients and families Children's Hospitals' Solutions for Patient Safety (SPS) - 2016 patient safety awareness week materials EngagingPatients.org - patient and family reporting: new knowledge, new advances Improving safety: engaging with patients and families makes a difference! Joint Commission - Speak Up: prevent errors in your child's care Justin's HOPE - Pediatric Safety Project Listen to parents of sick children rather than tests, NHS tells doctors NHS England - Respond to Ailing Child Tool (Re-ACT) Parents' perspectives on "keeping their children safe" in the hospital Partnering with parents and families to provide safer care: seeing and achieving safer care through the lens of patients and families Piece of my mind. After the medical error PIPSQC - protecting children from harm in pediatrics: lessons learned from parents (slides) RCPCH - safe system framework for children at risk of deterioration RCPCH - Situation Awareness for Everyone (S.A.F.E) - Royal Free Hospital parent and patient engagement poster SickKids - advancing child and family-centered care at SickKids: grounded by an organizational assessment (slides) SickKids - building the connection for patient safety: engaging the patient and changing the organization (slides) General: ACSQHC - National Safety and Quality Health Service (NSQHS) Standard 2: partnering with consumers AHRQ - guide to improving patient safety in primary care settings by engaging patients and families AHRQ - guide to patient and family engagement in hospital quality and safety Care 2 Collaborate - Advancing Partnerships in Care CPSI - patient engagement resources CPSI - SHIFT to Safety Engagingpatients.org - best practices Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction Feeling unsafe in the healthcare setting: patients' perspectives HRET - a leadership resource for patient and family engagement strategies HRET - Hospital Engagement Network (HEN) 2.0 - patient and family engagement IHI - Always Events framework Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm IPFCC - Leveraging the principles of high reliability to advance patient and family engagement in safety MHA Keystone - advancing patient- and family-centered care in Michigan - a road map to patient and family engagement Nine ways to avoid self-care mistakes NPSF - united for patient safety - resources Patient safety: a public health crisis for a nation of patients Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study Roadmap for patient and family engagement in healthcare practice and research ThinkSAFE - patient safety support for patients, families and carers Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites WHO - exploring patient participation in reducing health care related safety risks WHO - framework on integrated people-centred health services WHO - Patients for Patient Safety (PFPS) - feature projects - WHO global framework on patient and family engagement
Patient Identification	CHIME unveils national patient identifier challenge finalists Evaluating serial strategies for preventing wrong-patient orders in the NICU Joint Commission - patient identification Managing the patient identification crisis in healthcare and laboratory medicine PIPSQC - two patient identifiers and patient safety: a case of mistaken identity Preventable, potentially fatal patient identification errors analyzed by ECRI Institute Patient Safety Organization (PSO) Reduction in pediatric identification band errors: a quality collaborative When doctors get the wrong patient
Patient Safety Indicators (PSIs)	Australia: CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development Europe: ISD Scotland - care quality indicators - specialist children's services ISD Scotland - other information on child health NHS - Children and Young People's Services (C&YPS) Safety Thermometer NHS - Hospital Episode Statistics - inpatient, outpatient, and A&E records Set of quality indicators of pediatric intensive care in Spain: Delphi method selection North America: AAP - pediatric clinical quality measures to be part of meaningful use program in 2014 AHRQ - chartbook on patient safety AHRQ - measuring patient safety events: opportunities and challenges AHRQ - national quality measures clearing house - measure matrix AHRQ - new system aims to improve patient safety monitoring AHRQ - Pediatric Quality Indicators (PDIs) AHRQ - pediatric toolkit for using the AHRQ quality indicators AHRQ - quality indicators AHRQ - quality measure tools & resources - child health care quality toolbox AHRQ - quality and safety review system AHRQ PSNet - America's hospitals: improving quality and safety - the joint commission's annual report 2015 Associations between hospital characteristics, measure reporting, and the Centers for Medicare & Medicaid Services overall hospital quality star ratings Assumptions of quality medicine: the role of uncertainty Building a highway to quality health care CAPHC - measurement to action - the Hospital Harm Indicator CHA - developing new pediatric quality measures CIHI - 1 in 18 patients experiences harm in Canadian hospitals CIHI - hospital harm project CMS validated hospital inpatient quality reporting program data, but should use additional tools to identify gaming CMS - 2014 Clinical Quality Measures (CQM) - pediatric recommended core set table Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program Concerns about using the Patient Safety Indicator-90 composite in pay-for-performance programs CPSI - hospital harm measure Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data Developing measures for pediatric quality: methods and experiences of the CHIPRA pediatric quality measures program grantees Dissecting Leapfrog: how well do Leapfrog Safe Practices Scores correlate with Hospital Compare ratings and penalties, and how much do they matter? Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures Fostering transparency in outcomes, quality, safety, and costs From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system Hospital Safety Grade Hospital Safety Grade - lives lost and lives saved HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program IOM - vital signs: core metrics for health and health care progress Impact of Medicare's nonpayment program on hospital-acquired conditions Importance of the pediatric quality measurement program in advancing children’s health care: a view from children’s hospitals Innovative use of the electronic health record to support harm reduction efforts Investigating adverse event free admissions in medicare inpatients as a patient safety indicator Is preventable harm the right patient safety metric? Joint Commission - America's hospitals: improving quality and safety - The Joint Commission's annual report 2016 Leapfrog gives a third of U.S. hospitals an 'A' for safety Leapfrog hospital safety score, Magnet designation, and healthcare-associated infections in United States hospitals Leapfrog hospital survey Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future) Measurement as a performance driver: the case for a national measurement system to improve patient safety Medicare failed to investigate suspicious infection cases from 96 hospitals Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach New CMS hospital quality star ratings: the stars are not aligned NHS - NHS Safety Thermometer NQF - patient safety project 2015-2017 NQF - pediatric measures OPENPediatrics - update on pediatric index of mortality Predictors of gaps in patient safety and quality in U.S. hospitals Preventable Harm Index: an effective motivator to facilitate the drive to zero Secret data on hospital inspections may soon become public Self-reported quality measures don't add up, study says UHC - Safety Intelligence (powered by Datix) Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
Patient Safety Priority Areas	Paediatric: Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study AHRQ - patient safety in the context of perinatal, neonatal, and pediatric care (grant) Building a culture of safety in pediatrics and child health Can a quality improvement project impact maternal and child health outcomes at scale in northern Ghana? CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review CEC - pediatric quality program Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2016) Children's Hospitals' Solutions for Patient Safety (SPS) - our focus CPSI - Canadian Paediatric Adverse Events Study (CPAES) Ending Preventable Child and Maternal Deaths - A Promise Renewed (APR) - resources Health care learning networks: widespread effort to eliminate medical errors among kids Improving safety for pediatric patients International Pediatric Association (IPA) - Quality of Care (QoC) Making it Safer Together (MiST) paediatric patient safety collaborative - safety themes Moving the needle in children's health with national collaborative networks - a CEO's perspective NHS - Children and Young People's Services (C&YPS) Safety Thermometer NHS - review of patient safety for children and young people NHS England - Sign Up to Safety: children and young people’s patient safety expert group NPSF - making quality and safety a priority in health care for our children Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement PIPSQC - accelerating change - learning from each other to decrease healthcare-associated harm (slides) PIPSQC - IHI 25th Annual National Forum - PIPSQC workshop 2013 PIPSQC - International Forum on Quality & Safety in Healthcare - PIPSQC workshop 2012 PIPSQC - PIPSQC roundtable discussion 2006 Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the paediatric trigger tool Preventing health care-associated harm in children Principles of pediatric patient safety: reducing harm due to medical care Quality of care for pregnant women and newborns - the WHO vision Reducing mortality related to adverse events in children Safe pediatric care delivery Top 10 interventions in paediatric patient safety WHO - better hospital care for children WHO - improving paediatric quality of care at first-level referral hospitals WHO - launch of the network to improve quality of care for mothers, newborns and children WHO - maternal, newborn, child and adolescent health - documents on quality of care WHO - quality of care for every pregnant woman and newborn WHO - standards for improving quality of maternal and newborn care in health facilities Australia: CEC - patient safety programs Europe: CQC - state of care in NHS acute hospitals: 2014 to 2016 Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews Health Foundation - continuous improvement of patient safety Health Foundation - creating a new improvement research institute IHM - Review of Reviews Impact of medical errors and malpractice on health economics, quality, and patient safety Imperial College London - patient safety 2030 Imperial College London - reports Imperial College London - safer healthcare: strategies for the real world Imperial College London - too many avoidable errors in patient care, says report Imperial College London - transforming patient safety: a sector-wide systems approach More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England? Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach NHS England - priority areas for patient safety collaboratives NHS Scotland - chief medical officer's annual report (2014-15) - realistic medicine NHS 'standing on burning platform' of outdated acute care model Patient safety is not a luxury Rethinking patient safety North America: 8 ways to improve hospital patient safety - efforts start with culture, say leaders at the NPSF Congress AHRQ - AHRQ supports hospitals as they make care safer AHRQ - chartbook on patient safety AHRQ - making health care safer II - an updated critical analysis of the evidence for patient safety practices AHRQ - national patient safety efforts save 125,000 lives and nearly $28 billion in costs AHRQ - national quality strategy - making care safer AHRQ - national scorecard on rates of hospital-acquired conditions 2010 to 2015: interim data from national efforts to make health care safer AHRQ - patient safety measure tools & resources AHRQ - patient safety measure tools & resources - patient safety tools & resources AHRQ - strengthening AHRQ's role in preventing medical errors AHRQ - we're keeping score: reducing hospital-acquired conditions AHRQ PSNet - primers Building a highway to quality health care Changing the narratives for patient safety CIHI - hospital harm project CMS awards $347 million to continue progress toward a safer health care system CMS invites quality innovation network-quality improvement organizations to submit special innovation projects to expand their reach in improving care delivery CMS - Partnership for Patients (PfP) CMS - Partnership for Patients (PfP) - Hospital Engagement Network (HEN) 2.0 - final report CMS - Partnership for Patients (PfP) - Hospital Innovation Improvement Networks (HIINs) CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine Don Berwick's 7 roadblocks to improving patient safety Dr. Don Berwick: 5 big missteps on the patient safety journey ECRI Institute - top 10 health technology hazards for 2017 ECRI Institute - top 10 patient safety concerns for healthcare organizations 2016 Estimating deaths due to medical error: the ongoing controversy and why it matters Fifteen years after to err is human: a success story to learn from Fostering transparency in outcomes, quality, safety, and costs Hospital Engagement Network Results Show 34,000 Harms Prevented Hospital Safety Grade - lives lost and lives saved IHPME - beyond the quick fix: strategies for improving patient safety Improving safety for hospitalized patients - much progress but many challenges remain Joint Commission - national patient safety goals Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System Medical error-the third leading cause of death in the US NPSF - five notable developments in patient safety in 2016 NPSF - free from harm: accelerating patient safety improvement fifteen years after to err is human NPSF - Institute for Healthcare Improvement and NPSF agree to merger NPSF - into the future with IHI, together for safer care NPSF - preventable health care harm is a public health crisis NPSF - time to step on the accelerator NPSF - transforming health care: a compendium of reports from the NPSF Lucian Leape Institute Patient safety at the crossroads Patient safety initiatives are everybody's business Patient Safety Movement - challenges & solutions Patient safety: a public health crisis for a nation of patients Pennsylvania Patient Safety Authority - health literacy and patient safety events - patient safety authority annual reports PIPSQC Blog - patient harm is a public health crisis, not just a performance management issue Preventable harm in healthcare a public health crisis Redefining patient safety in 2017 - 6 thoughts from IHI CEO Derek Feeley Rethinking medical ward quality Strategies to improve patient safety: the evidence base matures Top patient safety strategies that can be encouraged for adoption now What practices will most improve safety? Evidence-based medicine meets patient safety Why are medical errors still a leading cause of death? Global: IHI - IHI's work around the world Federal Ministry of Health - best practices in patient safety: 2nd global ministerial summit on patient safety Federal ministry of health - economics of patient safety: strengthening a value-based approach to reducing patient harm at national level Federal Ministry of Health - patient safety summit 2017 - patient safety takes the front seat Joint Commission - international patient safety goals Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review SafeCare - SafeCare Standards - for health centres in resource-restricted settings WHO - African Partnerships for Patient Safety (APPS) WHO - global priority areas for patient safety research WHO - patient safety - implementing change WHO - patient safety tool kit (2015) WHO - quality of care for pregnant women and newborns: the WHO vision
Peer-to-Peer (P2P) Assessment	Clinical perspective: creating an effective practice peer review process - a primer Five lessons healthcare leaders are learning from an unlikely source: nuclear power Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry Toward improving patient safety through voluntary peer-to-peer assessment
Poisoning Prevention	CDC - PROTECT initiative: advancing children's medication safety Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings NHS - patient safety alert - risk of death and serious harm from delays in recognising and treating ingestion of button batteries Re-ACT Talks: Batteries, Burns and other Bombs
Precision Public Health	CDC - precision public health and precision medicine: two peas in a pod Dr. Susan Desmond-Hellmann, Guide of the Gates Foundation Medscape - 'all lives have equal value': reducing inequality with precision public health Precision public health: big data's next big idea TED - a smarter, more precise way to think about public health UCSF - precision public health summit: the first 1000 days Why The First 1,000 Days Matter Most
Prehospital Care	See 'Emergency Medical Services (EMS)'
Primary Care	See 'Ambulatory Care'
Quality Measures	See 'Patient Safety Indicators (PSIs)'
Radiation in Imaging	ACR - pediatric radiation safety Alliance for Radiation Safety in Pediatric Imaging - Image Gently Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering Key principles in quality and safety in radiology Pediatric chest radiographs: common and less common errors Overuse of medical imaging and its radiation exposure: who's minding our children? Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support Radiologic safety events within a pediatric emergency medicine network Radiology research in quality and safety: current trends and future needs Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies WHO - communicating radiation risks in paediatric imaging - information to support healthcare discussions about benefit and risk WHO - international workshop on radiation risk communication in paediatric imaging
Rapid Response Team (RRT)	ACSQHC - recognising and responding to clinical deterioration - guide to implementation of the national consensus statement CHEO - CHEO's SPOT Team - family activated critical care response team Cincinnati Children's - emergency codes outside the ICU Cost-benefit analysis of a medical emergency team in a children’s hospital Developing and evaluating the success of a family activated medical emergency team: a quality improvement report High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training Impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review Improving the recognition of, and response to in-hospital sepsis Josie King Foundation - Condition Help (Condition H) Multicenter collaborative approach to reducing pediatric codes outside the ICU NUH - Recognise and Rescue: A hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals NHS Trust NUH - 'Recognise and Rescue' - improving the care of the deteriorating pediatric patient Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams Pediatric medical emergency team events and outcomes: a report of 3647 events from the American Heart Association's Get With the Guidelines-Resuscitation registry Queensland Health - Ryan's Rule - consumer/family escalation process Rapid response systems: a systematic review and meta-analysis Real-time risk prediction on the wards: a feasibility study Royal Children's - escalation of care flowchart Royal Children's - Victorian Children's Tool for Observation and Response (ViCTOR) Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides)
Readmissions and Care Transitions	Paediatric: CAPHC - 'Passport' helps parents plan move from hospital to home Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles - readmissions Pediatric hospitalists collaborate to improve timeliness of discharge communication General: 30-day potentially avoidable readmissions due to adverse drug events AHRQ - designing and delivering whole-person transitional care: hospital guide to reducing Medicaid readmissions AHRQ - Re-Engineered Discharge (RED) toolkit An Obamacare success: financial penalties reduce hospital readmission rates Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions Bigger readmissions penalties linked to declining rates Carelink CareNow CMS - Partnership for Patients (PfP) - readmissions and care transitions Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program Identifying and reducing complications after emergency room discharge Impact of discharge planning decision support on time to readmission among older adult medical patients Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study Improving communication with primary care physicians at the time of hospital discharge Joint Commission - Transitions of Care (ToC) portal Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System Nationwide Readmissions Database (NRD) NPSF - creating structure for sharing information and knowledge in ambulatory care: two exemplars Readmission rates after passage of the Hospital Readmissions Reduction Program: a pre-post analysis Reducing Avoidable Hospital Readmissions (RARE) Understanding patient-centred readmission factors: a multi-site, mixed-methods study Using automated surveillance to improve diagnosis
Reporting	AHRQ - Patient Safety Organization (PSO) program Barriers and facilitators of adverse event reporting by adolescent patients and their families BC Children's - establishing a pediatric family-initiated safety reporting program (slides) BC Children's - patient's view: seeing safety through the eyes of families at BC Children’s Hospital BC Children's - what a family perspective teaches about adverse events in the pediatric setting (slides) Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention CHA - Child Health Patient Safety Organization (PSO) CMS validated hospital inpatient quality reporting program data, but should use additional tools to identify gaming Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU Effects of power, leadership and psychological safety on resident event reporting Electronic approaches to making sense of the text in the adverse event reporting system EngagingPatients.org - patient and family reporting: new knowledge, new advances Families as partners in hospital error and adverse event surveillance Impact of hazard telephone reporting system on patient safety Imperial College London - too many avoidable errors in patient care, says report Implementation and evaluation of a prototype consumer reporting system for patient safety events Improvement approach to integrate teaching teams in the reporting of safety events Improving patient safety reporting with the common formats: common data representation for Patient Safety Organizations Increasing patient safety event reporting in an emergency medicine residency Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care Innovative use of the electronic health record to support harm reduction efforts International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process ISMP - using information from external errors to signal a "clear and present danger" Learning from Excellence (LfE) - a call to learn from what goes well in healthcare Learning from excellence in healthcare: a new approach to incident reporting Legislative report to the general assembly: adverse event reporting Making residents part of the safety culture: improving error reporting and reducing harms Measurement as a performance driver: the case for a national measurement system to improve patient safety Medicare failed to investigate suspicious infection cases from 96 hospitals Multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting NHS - organisation patient safety incident reports NHS - Children and Young People's Services (C&YPS) Safety Thermometer NHS England - Development of the Patient Safety Incident Management System (DPSIMS) NPSF - patient complaints and post-operative complications Operational failures detected by frontline acute care nurses Parent-reported errors and adverse events in hospitalized children Patient reported approach to identify medical errors and improve patient safety in the emergency department Patient reporting and action for a safe environment (PRASE) intervention: a feasibility study Patient safety incidents are common in primary care: a national prospective active incident reporting survey PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety Safety App Screening electronic health record-related patient safety reports using machine learning Secret data on hospital inspections may soon become public Using an inpatient portal to engage families in pediatric hospital care Why are medical errors still a leading cause of death?
Researcher-in-Residence	Moving improvement research closer to practice: the Researcher-in-Residence model
Resident Physicians	See 'Junior Doctors'
Resuscitation	See 'CPR and Resuscitation'
Reverse Innovation	IHI - a two-way street: what the united states can learn from resource-limited countries to improve health care delivery and reduce costs Reverse innovation in global health systems: learning from low-income countries Turning the World Upside Down: The Search for Global Health in the 21st Century WHO - turning the world upside down
Root Cause Analysis (RCA)	AHRQ PSNet - conversation on root cause analysis w Dr. Bagian AHRQ PSNet - rethinking root cause analysis Design and testing of BACRA, a web-based tool for middle managers at health care facilities to lead the search for solutions to patient safety incidents How to perform a root cause analysis for workup and future prevention of medical errors: a review Improving apparent cause analysis reliability: A quality improvement initiative Investigating the causes of adverse events NPSF - implementing root cause analysis and actions: lessons learned from the journey NPSF - RCA2: improving root cause analyses and actions to prevent harm Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? Patient Safety: investigating and reporting serious clinical incidents Retained lumbar catheter tip Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education Root-cause analysis: swatting at mosquitoes versus draining the swamp Unbundling the bundles: using apparent and systemic cause analysis to prevent health care-associated infection in pediatric intensive care units
Safety Culture	AHA - HPOE - profiles in excellence: quality improvement lessons from the AHA-Mckesson Quest for Quality Prize recipients part 1 AHRQ - hospital survey on patient safety culture AHRQ PSNet - primers - safety culture As a critical behavior to improve quality and patient safety in health care: speaking up! ASSI - safety culture Building a culture of safety in pediatrics and child health Building a high-reliability organization: one system's patient safety journey Center for Patient Safety - just culture Changing the narratives for patient safety Children's Hospitals' Solutions for Patient Safety (SPS) - network design & process Cincinnati Children's - 'Being the best at getting better' - creating a culture of change CMS - Partnership for Patients (PfP) - culture Common predictors of nurse-reported quality of care and patient safety Comparing NICU teamwork and safety climate across two commonly used survey instruments Core principles of quality improvement and patient safety CQC - state of care in NHS acute hospitals: 2014 to 2016 Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation Do hospital boards matter for better, safer, patient care? Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction Exploring relationships between hospital patient safety culture and Consumer Reports safety scores From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system Health Foundation - continuous improvement of patient safety Health Foundation - framework for measuring and monitoring safety Health Foundation - measurement and monitoring of safety Health Foundation - pursuing zero - a winning approach to safety Health Foundation - what we know about how to improve quality and safety in hospitals - and what we need to learn Healthcare Performance Improvement (HPI) HRET - Hospital Engagement Network (HEN) 2.0 - culture of safety IHI - building systems of safety IHI - decision tree for unsafe acts culpability IHI - develop a culture of safety IHI - framework for safe, reliable, and effective care IHI - IHI virtual expedition: understanding and improving safety culture IHI - patient safety framework IHI: this way to patient safety Imperial College London - safer healthcare - strategies for the real world Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system Joint Commission - essential role of leadership in developing a safety culture Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition Joint Commission - quick safety 22: patient safety systems chapter Joint Commission - safety culture and high reliability: stages of organizational maturity Joint Commission Center for Transforming Healthcare - safety culture Just culture: balancing safety and accountability, third edition 'Just culture:' improving safety by achieving substantive, procedural and restorative justice KK Women's and Children's Hospital - patient safety - building a reliable culture for a sustainable outcome Long and winding road toward greater quality and safety - Memorial Hermann and Virginia Mason health systems make big leaps in improving patient safety Massachusetts Coalition for the Prevention of Medical Errors - 2017 Patient Safety Forum MedStar Health - quality and patient safety - quality & safety videos MedStar Health - safety across the board: integrating "just culture", high reliability, and open, honest communication Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach NHS - developing people - improving care - a national framework for action on improvement and leadership development in NHS-funded services NPSF - leading a culture of safety: a blueprint for success Outcome Engenuity - introduction to just culture Patient safety at the crossroads Patient safety efforts need engaged leaders Pediatric quality and safety: a nursing perspective Preventable Harm Index: an effective motivator to facilitate the drive to zero Prevention is better than cure: learning from adverse events in healthcare Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study RCPCH - safe system framework for children at risk of deterioration Re-examining high reliability: actively organising for safety Rethinking patient safety Revisiting the quality chasm Quality and Safety in European Union Hospitals - a research-based guide for implementing best practice and a framework for assessing performance (QUASER) Quality and safety in nursing: a competency approach to improving outcomes, second edition Safety culture transformation: its effects at a children's hospital Safety lessons from the NIH clinical center Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety Safety perceptions of health care leaders in 2 Canadian academic acute care centers SickKids - Caring Safely Sidney Dekker - safety differently - talks Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies Systematic review of measurement tools for the proactive assessment of patient safety in general practice Towards high-reliability organising in healthcare: a strategy for building organisational capacity WSHA - toolkit: patient safety transforming culture
Safety-II and Resilience Engineering	Centre for Applied Resilience in Healthcare (CARe) - fact sheets Centre for Applied Resilience in Healthcare (CARe) - implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol David Woods - creating safety by engineering resilience Defining the role of social sciences in patient safety (special issue) Erik Hollnagel - ideas Eurocontrol - from safety I to safety II - a white paper Eurocontrol - systems thinking for safety: ten principles - a white paper - moving towards safety-II Humanistic Systems - systems thinking for safety: ten principles (a white paper) IHI - framework for safe, reliable, and effective care IHI: this way to patient safety International prize in resilient health care Learning from Excellence - Adrian Plunkett (video) Learning from Excellence (LfE) - a call to learn from what goes well in healthcare Learning from excellence in healthcare: a new approach to incident reporting National Center for Human Factors in Healthcare - resilience engineering in health care Reliability engineering & system safety - resilience engineering (special issue) Resilience and precarious success: how human adaptation keeps patients safe Resilience and resilience engineering in health care Resilient Health Care Net (RHCN) Resilient Health Care Net (RHCN) - is counting accidents a measure of safety? Resilient Health Care Net (RHCN) - from safety-I to safety-II: a white paper Resilient Health Care Net (RHCN) - meeting presentations 2016 Resilient Health Care Net (RHCN) - overview of the Resilience Assessment Grid (RAG) Resilient Health Care Net (RHCN) - resilient health care: turning patient safety on its head Resilient Health Care Net (RHCN) - safety II: actuated Resilient health care, volume 3: reconciling work-as-imagined and work-as-done Safety-I, Safety-II and resilience engineering Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems
Second Victim	See 'Employee Safety'
Sentinel Events	Correlates of the third victim phenomenon CPSI - Global Patient Safety Alerts CPSI - never events for hospital care in Canada ISMP - using information from external errors to signal a "clear and present danger" Leapfrog - one in five U.S. hospitals fail to adopt crucial 'Never Events' policies Joint Commission - sentinel event alert 'Never Events' and the quest to reduce preventable harm NQF - serious reportable events Prevention is better than cure: learning from adverse events in healthcare Retained lumbar catheter tip Secret data on hospital inspections may soon become public
Sepsis	Fluid Restriction: Challenges for treating sepsis in African children (slides) Combined feasibility and external pilot study to inform the design and conduct of the Fluids in Shock (FiSh) trial Conservative vs. liberal approach to fluid therapy of septic shock in intensive care (CLASSIC) FEAST - 5 years on FEAST and paediatric fluid resuscitation Fluids and kids: what now? (slides) Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice Mortality after fluid bolus in African children with severe infection Pediatric sepsis and septic shock management in resource-limited settings Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score SQUEEZE trial: trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal directed fluid-sparing strategy vs. usual care (SQUEEZE) WHO guidance 'risks killing children' WHO guidelines on fluid resuscitation in children: missing the FEAST data WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline Australia: CEC - Sepsis Kills - toolkit - paediatric Improving the recognition of, and response to in-hospital sepsis SEPSIS KILLS: early intervention saves lives Europe: Comparison of pediatric severe sepsis managed in U.S. and European ICUs HSE - sepsis - sepsis management national clinical guideline No. 6 Leicester Hospital - Paediatric Sepsis Box Making the journey safe: recognising and responding to severe sepsis in accident and emergency NHS 111 'missed chances to save sepsis baby William Mead' NHS Wales - 1000 Lives Improvement - Sepsis Six Pathway box NICE - sepsis: recognition, diagnosis and early management NUH - Recognise and Rescue: a hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals NUH - 'Recognise and Rescue' - improving the care of the deteriorating pediatric patient Rocialle's new Single-Use Sepsis Box is being trialled by Cwm Taf UHB Sepsis in children - what is in a name? Single-use kit aims to reduce the risk of sepsis SPSP - paediatric care - Paediatric Sepsis 6 UK Sepsis Trust - acute paediatric toolkit UK Sepsis Trust - acute paediatric toolkit - Paediatric Sepsis 6 Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care North America: Ambient Clinical Analytics - syndromic surveillance - Sepsis Detection and Response Tool (Sepsis DART) Automated detection of sepsis using electronic medical record data: a systematic review Boy's life is lost to sepsis. Thousands are saved in his wake CAPHC - Canada's ambitions for pediatric sepsis screening: from today's best practice to precision medicine CAPHC - global burden of sepsis: World Sepsis Day, September 13 CAPHC - paediatric sepsis: importance of data as a foundation for improvement CAPHC - Paediatric Sepsis Screening Tool CAPHC - please join us in thanking the CAPHC sepsis community of practice CDC - Think Sepsis. Time Matters. CHA - children's hospitals have a voice at national sepsis forum CHA - Improving Pediatric Sepsis Outcomes (IPSO) CHA - join the fight against pediatric sepsis with new collaborative CHA - national sepsis expert: children's hospitals can mobilize to reduce severe sepsis and sepsis deaths CHA - nursing on the front lines of the battle against pediatric sepsis: a webinar for clinicians CHA - sepsis CHA - sepsis awareness month CHA - sepsis: battling a leading cause of death in hospitalized children CHA - sepsis webinar series Cincinnati Children's - new test accurately predicts mortality risk in pediatric septic shock Cincinnati Children's - sepsis alert trigger and automated team response Clinical decision support for early recognition of sepsis Developing the surveillance algorithm for detection of failure to recognize and treat severe sepsis Empowered Patient Coalition - Pediatric Warning Signs and Symptoms of Flu-like Illness HRET - Hospital Engagement Network (HEN) 2.0 - sepsis Identifying patients with sepsis on the hospital wards IHI - WIHI: a partnership to reduce deaths from sepsis Infection, unnoticed, turns unstoppable Implementation of an inpatient pediatric sepsis identification pathway New York State report on sepsis care improvement initiative: hospital quality performance (2015) Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program Rory Staunton Foundation - sepsis protocols Rory Staunton Foundation - Rory's Regulations Sepsis in Canadian children: a national analysis using administrative data SickKids piloting new pathway for early recognition & management of sepsis State sepsis mandates - a new era for regulation of hospital quality Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides) Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention With help from IHI, North Shore-LIJ reduces sepsis mortality rate by 50% in 5 years, saving thousands of lives Global: Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. CAPHC - misdiagnosed 'sepsis' now a global health priority for world health organization Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial International Pediatric Association (IPA) - joint statements - managing possible serious bacterial infection in young infants 0-59 days old when referral is not feasible Key points in pediatric sepsis and septic shock (slides) Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study OPENPediatrics - the burden of sepsis in children (webinar) OPENPediatrics - sepsis in the critically ill child (webinar) Pediatric sepsis and septic shock management in resource-limited settings PICC 2016 - sepsis: moving forward PICC 2016 - session summaries - sepsis sessions 1 & 2 Sepsis Global Alliance (SGA) Sepsis guideline implementation: benefits, pitfalls and possible solutions Sepsis - a neglected global killer (slides) Stop sepsis - the Global Sepsis Alliance (slides) Surviving Sepsis Campaign - guidelines Third international consensus definitions for sepsis and septic shock (Sepsis-3) WFPICCS - sepsis initiative WHO - critical care training short course - clinical management of patients with severe forms of influenza infection WHO - Ending Maternal and Newborn Sepsis Week 2017 WHO - Global Maternal and Newborn Sepsis Initiative WHO - innovation through partnership - achieving more together than alone WHO - management of newborn illness and complications WHO - managing possible serious bacterial infection in young infants when referral is not feasible World Sepsis Congress World Sepsis Congress - burden of sepsis in children - innovative critical care World Sepsis Congress - challenges of sepsis management in low-income settings World Sepsis Congress - effective interventions for mothers and newborns World Sepsis Congress - program
Serious Safety Events (SSEs)	ASHRM - serious safety events: a focus on harm classification - deviation in care as link ASHRM - serious safety events: getting to zero™ white paper edition no. 1 ASHRM - serious safety events: getting to zero™ white paper edition no. 2 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS operational definitions - SSEs Cincinnati Children's - serious safety events Correlates of the third victim phenomenon Healthcare Performance Improvement (HPI) - SEC & SSER patient safety measurement system for healthcare NHS England - serious incident framework Patient Safety: investigating and reporting serious clinical incidents Preventable Harm Index: an effective motivator to facilitate the drive to zero
Simulation	Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training Building a culture of patient safety through simulation CHA - simulation lab helps parents prepare to care for kids at home Cincinnati Children's - 'learning from dummies' Developing team cognition: a role for simulation Emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives Flying lessons for clinicians: developing system 2 practice Healthcare simulation dictionary High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training Hybrid methodology for modeling risk of adverse events in complex health-care settings Imperfect practice makes perfect: error management training improves transfer of learning In situ simulation In situ simulation: detection of safety threats and teamwork training in a high risk emergency department International Network for Simulation-based Pediatric Innovation, Research, & Education (INSPIRE) International Pediatric Simulation Society (IPSS) PRONTO - simulation & team training for obstetric & neonatal emergencies Realism in simulation: how much is enough? Resilient Health Care Net (RHCN) - resilience and simulation redux 'See one, sim one, do one' - a national pre-internship boot-camp to ensure a safer 'student to doctor' transition Simulation, mastery learning and healthcare Simulation for operational readiness in a new freestanding emergency department: strategy and tactics Simulation to predict effect of citywide events on emergency department operations Simulation-based training: the missing link to lastingly improved patient safety and health? Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls Using simulation to prepare nursing staff for the move to a new building
Situation Awareness	Ambient Clinical Analytics - Mayo Clinic YES Board - multi-patient dashboard \| real-time situational awareness Cincinnati Children's - CERT - CCHMC safety and risk-reduction projects Developing team cognition: a role for simulation Evaluating situation awareness: an integrative review Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis Health care huddles: managing complexity to achieve high reliability Healthcare Performance Improvement (HPI) - daily check in for safety Huddles and debriefings: improving communication on labor and delivery Huddling for high reliability and situation awareness IHI - WIHI: situational awareness and patient safety (webinar) Implementation of the safety huddle Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events Model can ID patients at risk for serious safety events PIPSQC - S.A.F.E - improving child health outcomes through situation awareness RCPCH - Situation Awareness for Everyone (S.A.F.E) Safety huddles to proactively identify and address electronic health record safety Situation awareness: a new model for predicting and preventing patient deterioration Situational awareness and emergent response systems in the context of stages of clinical deterioration in the hospital Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system Situational awareness - what it means for clinicians, its recognition and importance in patient safety SPSP - paediatric care - increased situational awareness to reduce undetected deterioration Step toward high reliability: implementation of a daily safety brief in a children's hospital Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards UHN - daily unit safety huddles part of Caring Safely transformation at UHN
Sleep and SIDS	AAP - SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment Interventions to improve safe sleep among hospitalized infants at eight children's hospitals Sleep Help Institute - Healthy Sleep for New and Expecting Parents Sleep Help Institute - Children's Sleep Guide Swaddling and the risk of sudden infant death syndrome: a meta-analysis To avoid SIDS, infants and parents should share a room, report says Tuck - parent's guide to healthy sleep
Staffing	Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England Association between elements of electronic health record systems and the weekend effect in urgent general surgery 'Busy day' effect on perinatal complications of delivery on weekends Doctors who only come out at night Introducing a new junior doctor electronic weekend handover on an orthopaedic ward Is the "July Effect" real? Pediatric trainee reported medical errors and adverse events Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records NHS England - seven day hospital services NHS England - supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care Nurses drive change in patient safety improvements Time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect? Weekend effect in children with stroke in the nationwide inpatient sample "Weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend Weekend emergency surgery 'not more risky' Weekend worriers What have we learnt after 15 years of research into the 'weekend effect'?
Standardisation of Care	See 'Cinical Effectiveness and Standardisation'
Surgery	Checklists: Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial Enhanced time out: an improved communication process Factors that drive team participation in surgical safety checks: a prospective study Impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility Impact of surgical safety checklists on theatre departments: a critical review of the literature Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care Innovative approach to the surgical time out: a patient-focused model Instrument count sheets and set reviews as patient safety tools Introductions during time-outs: do surgical team members know one another's names? Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016 Mortality trends after a voluntary checklist-based surgical safety collaborative Moulton Lab - slowing down to stay out of trouble in the operating room: remaining attentive in automaticity Operating room clinicians' attitudes and perceptions of a pediatric surgical safety checklist at 1 institution Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies Safe Surgery 2015 - safe surgery checklist implementation guide Safesurg.org - how to reduce deaths in surgical care globally - materials Safesurg.org - other institutions' checklists Simple checklist prevents deaths after surgery, a large new study suggests Time-out and checklists: a survey of rural and urban operating room personnel Time-out: the professional and organizational ethics of speaking up in the OR Tools and the trade: an ethnographic study of checklist policy and performance, and implications for patient safety WHO - Surgical Safety Checklist Paediatric: A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong ACS National Surgical Quality Improvement Program Pediatric (ACS NSQIP Pediatric) ACS National Surgical Quality Improvement Program: targeting quality improvement in Canadian pediatric surgery Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room BC Children's - team behaviours and non-technical skills in a paediatric surgical facility (slides) Improving pediatric surgery quality and outcomes in the 21st century (special issue) National aeronautics and space administration 'threat and error' model applied to pediatric cardiac surgery: error cycles precede ~85% of patient deaths Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery Nontechnical skills in pediatric surgery: factors influencing operative performance Optimal resources for children's surgical care 2015 Patient safety improvement interventions in children's surgery: a systematic review 'Weekend effect' in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend General: ACS National Surgical Quality Improvement Program (ACS NSQIP) ACS NSQIP Annual Conference - 2016 presentations ACS Updates Guidelines Regarding Overlapping Surgeries AHRQ - safety program for improving surgical care and recovery AHRQ - toolkit to improve safety in ambulatory surgery centers AORN position statement on patient safety Applying human-centered design thinking to enhance safety in the OR Association between implementation of a medical team training program and surgical mortality Association of periOperative Registered Nurses (AORN) - clinical resources Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training Association of unsolicited patient observations with the quality of a surgeon's care Brigham and Women's - Center for Surgery and Public Health Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery Concurrent and overlapping surgeries: additional measures warranted Current issues in patient safety in surgery: a review Cutting-edge efforts in surgical patient safety Failures in communication and information transfer across the surgical care pathway: interview study Fundamental Use of Surgical Energy (FUSE): an essential educational program for operating room safety Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries Implementing a standardized safe surgery program reduces serious reportable events Improving Rescue - bringing about collaboration to improve safety and quality of care Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data Joint Commission Center for Transforming Health - safe surgery project Learning and mindfulness: improving perioperative patient safety Medication safety in the operating room: literature and expert-based recommendations Microanalysis of video from the operating room: an underused approach to patient safety research Next wave of hospital innovation to make patients safer NPSF - patient complaints and post-operative complications On patient safety (special issue) Promoting civility in the OR: an ethical imperative Realism in simulation: how much is enough? Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis Senate committee calls for ban on surgeons conducting simultaneous operations Structured handover in general surgery: an audit of current practice Surgeon, heal thyself: optimising surgical performance by managing stress Surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study Surgical clinics - patient safety (special issue) Surgical never events and contributing human factors Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications We are going to name names and call you out! Improving the team in the academic operating room environment WHO - Safe Surgery Saves Lives
Teamwork Training	AHRQ - high reliability organizational culture using standardized patient simulation and TeamSTEPPS AHRQ - TeamSTEPPS 2.0 Amy Edmondson: Teaming Amy Edmondson's required reading Building the future: big teaming for audacious innovation Building high reliability teams: progress and some reflections on teamwork training Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care Developing team cognition: a role for simulation Examining the nature of interprofessional interventions designed to promote patient safety: a narrative review Google considers this to be the most critical trait of successful teams Harvard Business School - Amy C. Edmondson - faculty page Importance of teaming Improving care teams' functioning: recommendations from team science Interview with Amy C. Edmondson, author of "Teaming" by William Brandel, RCRC, Brandeis University Monitoring teamwork: a narrative review Patient safety improves when providers feel psychologically safe (video) Power of teaming (slides) Principles of shared decision-making within teams Saving lives: a meta-analysis of team training in healthcare Strategies for learning from failure (video) Systematic review of team training in health care: ten questions Team building and beyond - interview with Amy Edmondson, Harvard Business School (video) Team up, fail well, learn fast (slides) Teaming: how organizations learn, innovate, and compete in the knowledge economy Teaming to innovate Teaming to innovate (slides) Teams and learning in organizations (video) Teamwork on the fly Teamwork on the fly (excerpt) (PDF) TEDx - building a psychologically safe workplace: Amy Edmondson at TEDxHGSE (video) The Art Of - Amy Edmondson Thought leader interview: Amy Edmondson (PDF) Three pillars of a teaming culture
Telemedicine	See 'eHealth, mHealth, and Telehealth'
Transport	CAPHC - update - standards in interfacility transport of critically ill neonatal, paediatric and maternal patients Children's Acute Transport Service (CATS) - standard operating procedures Pediatric and neonatal interfacility transport: results from a national consensus conference Systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics
Trigger Tools	See 'Adverse Event Detection'
Triple Aim	IHI - 10 new rules to accelerate healthcare redesign IHI - radically redesigning patient safety IHI - Triple Aim initiative - better care for individuals, better health for populations, and lower per capita costs Quadruple Aim: care of the provider Triple Aim must turn into the Quadruple Aim. Here’s why. Why healthcare organizations must embrace the 'Quadruple Aim'
Tubing Misconnections	See 'Medical Devices'
Universal Health Coverage	WHO - global coalition calls for acceleration of access to universal health coverage WHO - service delivery and safety - quality in universal health coverage
Unplanned Extubations	Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates Children's National - reducing harm: impact of unplanned extubations (pages 10-14) Reducing unplanned extubations in the NICU Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events Unplanned extubations in children: impact on hospital cost and length of stay
Walkrounds	HRET - patient safety leadership walkrounds HSE - quality and safety walk-rounds Intentional rounding: a staff-led quality improvement intervention in the prevention of patient falls Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws
Weekend Effect	See 'Staffing'
Work Environment	AACN - healthy work environment assessment Monitoring the health of the work environment with a daily assessment tool: the REAL - Relative Environment Assessment Lens - indicator Work systems analysis approach to understanding fatigue in hospital nurses Workplace factors associated with burnout of family physicians
Zika	AAP - Zika virus CAPHC - Zika virus: a global issue in a Canadian context CDC - Zika virus CDC - Zika virus - information for clinicians CDC, AAP release algorithms on testing infants for Zika virus Premier - Zika virus infection guidance, tools and resources WHO - Zika virus WHO - Zika: we must be ready for the long haul Zika virus disease: a CDC update for pediatric health care providers