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1. CDC generally met its inspection goals for the federal select agent program: however, opportunities exist to strengthen oversight

Publication:
[Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, May 2017
Subject(s):
Government Regulation
Security Measures
Toxins, Biological
Federal Government
Laboratories -- standards
Risk Assessment
Risk Management
Humans
United States
United States. Department of Health and Human Services.
Centers for Disease Control and Prevention (U.S.)

2. HRSA helped health centers with elevated risks and can continue to take additional steps

Publication:
[Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, May 2018
Subject(s):
Financing, Government
Health Facilities -- economics
Medically Underserved Area
Health Services Accessibility -- economics
Quality of Health Care
Risk Management
Humans
United States
United States. Department of Health and Human Services.
United States. Health Resources and Services Administration.

3. Latex: a lingering and lurking safety risk

Author(s):
Liberatore, Kim, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, March 2018
Subject(s):
Latex Hypersensitivity -- prevention & control
Medical Errors -- statistics & numerical data
Latex -- adverse effects
Latex Hypersensitivity -- epidemiology
Patient Safety
Perioperative Care
Risk Management
Urinary Catheters -- adverse effects
Humans
Pennsylvania
United States

6. Oral medications inadvertently given via the intravenous route

Author(s):
Shah-Mohammadi, Ali-Reza, author
Gaunt, Michael J., author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, [2013]
Subject(s):
Medication Errors -- prevention & control
Medication Errors -- statistics & numerical data
Administration, Oral
Infusions, Intravenous
Injections, Intravenous
Patient safety
Pharmaceutical Preparations -- administration & dosage
Risk Management
Syringes
Humans
Pennsylvania
United States

7. Patient-to-patient aggression in the inpatient behavioral health setting

Author(s):
Gardner, Lea Anne, author
Magee, Mary C., author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, September 2014
Subject(s):
Aggression
Hospitals, Psychiatric
Inpatients
Risk Management
Violence -- statistics & numerical data
Adolescent
Adult
Aged
Child
Environment
Mental Health
Middle Aged
Patient safety
Patient-Centered Care
Professional-Patient Relations
Psychiatric Status Rating Scales
Risk Factors
Humans
Pennsylvania
United States

8. Omission of high-alert medications: a hidden danger

Author(s):
Grissinger, Matthew, author
Alghamdi, Dalia, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2014
Subject(s):
Drug Prescriptions
Drug Therapy -- statistics & numerical data
Medication Errors -- prevention & control
Infusion Pumps
Infusions, Intravenous
Medical Order Entry Systems
Patient safety
Pharmaceutical Preparations -- administration & dosage
Risk Management
Humans
Pennsylvania
United States

9. Oral anticoagulants: a review of common errors and risk reduction strategies

Author(s):
Andreica, Ivyruth, author
Grissinger, Matthew, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, June 2015
Subject(s):
Anticoagulants -- adverse effects
Anticoagulants -- therapeutic use
Medication Errors -- prevention & control
Medication Therapy Management
Administration, Oral
Anticoagulants -- administration & dosage
Drug Monitoring
Drug Prescriptions -- standards
Inservice Training
International Normalized Ratio
Risk Management
Humans
Pennsylvania
United States

11. Missed respiratory therapy treatments: underlying causes and management strategies

Author(s):
Wallace, Susan, author
Gardner, Lea Anne, author
Roper, Christine, author
Publication:
[Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, March 2016
Subject(s):
Medical Errors -- prevention & control
Respiratory Therapy
Continuity of Patient Care
Medical Errors -- statistics & numerical data
Medication Errors
Patient Care Team
Patient Education as Topic
Personnel Staffing and Scheduling
Respiration Disorders -- therapy
Respiratory System Agents -- therapeutic use
Risk Management
Treatment Refusal
Humans
Pennsylvania
United States

12. Newborns pose unique identification challenges

Author(s):
Wallace, Susan C., author
Publication:
[Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, June 2016
Subject(s):
Infant, Newborn
Medical Errors -- prevention & control
Patient Identification Systems -- methods
Medical Errors -- statistics & numerical data
Medication Errors -- statistics & numerical data
Patient safety
Risk Management
Humans
Pennsylvania
United States

13. Prescribing errors that cause harm

Author(s):
Rider, Briana B., author
Guant, Michael J., author
Grissinger, Mathew, author
Publication:
[Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, September 2016
Subject(s):
Medication Errors -- adverse effects
Medication Errors -- prevention & control
Medication Errors -- statistics & numerical data
Medical Order Entry Systems
Patient safety
Risk Management
Humans
Pennsylvania
United States

14. Process assessment is key to prevention of certain ophthalmology events

Author(s):
Magee, Mary C., author
Publication:
[Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, September 2016
Subject(s):
Cataract Extraction -- adverse effects
Lens Implantation, Intraocular -- adverse effects
Medical Errors -- prevention & control
Medical Errors -- statistics & numerical data
Process Assessment (Health Care)
Forecasting
Medical Errors -- trends
Medication Errors -- statistics & numerical data
Patient safety
Risk Management
Humans
Massachusetts
Pennsylvania
United States

26. Creating a culture for innovation and risk taking in transformative times

Author(s):
Rourke, Tym, author
Shugarman, Lisa R., author
Wong, Liane, author
Publication:
[Washington, D.C.] : Grantmakers in Health, March 25, 2013
Subject(s):
Dual MEDICAID MEDICARE Eligibility
Financial Support
Foundations
Health Care Reform -- legislation & jurisprudence
Organizational Culture
Organizational Innovation
Risk Management
Humans
United States
United States.

27. Frequent monitoring and behavioral assessment: keys to the care of the intoxicated patient

Author(s):
Magee, Mary C., author
Horine, Timothy, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, June 2017
Subject(s):
Alcoholic Intoxication -- therapy
Health Facilities
Patient safety
Safety Management
Alcoholic Intoxication -- epidemiology
Behavior Observation Techniques
Dangerous Behavior
Mental Health Services
Problem Behavior
Risk Management
Humans
Pennsylvania
United States

28. Safe health care for all patients: Pennsylvania Patient Safety Authority annual report : 2016

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, April 28, 2017
Subject(s):
Medical Errors -- prevention & control
Medical Errors -- statistics & numerical data
Patient safety
Risk Management
Cross Infection -- epidemiology
Cross Infection -- prevention & control
Delivery of Health Care -- organization & administration
Forecasting
Infection control
Mandatory Reporting
Medical Errors -- trends
Humans
Pennsylvania
United States

29. Design considerations and pre-market submission recommendations for interoperable medical devices: guidance for industry and Food and Drug Administration staff

Publication:
Silver Spring, MD : Center for Devices and Radiological Health, September 6, 2017
Subject(s):
Equipment and Supplies -- standards
Equipment Design -- standards
Equipment Safety -- standards
Device Approval
Equipment Failure
Information Dissemination
Risk Management
Humans
United States
United States. Department of Health and Human Services.
United States. Food and Drug Administration.

30. Veterans' health care: limited progress made to address concerns that led to high-risk designation : testimony before the Committee on Veterans' Affairs, U.S. Senate

Publication:
Washington, D.C. : U.S. Government Accountability Office, March 15, 2017
Subject(s):
Risk Assessment
Risk Management
Veterans Health
Efficiency, Organizational
Quality Assurance, Health Care
Humans
United States
United States. Department of Veterans Affairs.

31. How portfolios evolve after retirement: the effect of health shocks

Publication:
Chestnut Hill, MA : Center for Retirement Research at Boston College, c2005
Subject(s):
Catastrophic Illness -- economics
Financial Management -- economics
Retirement -- economics
Age Factors
Aged
Aged, 80 and over
Aging
Forecasting
Health Status
Middle Aged
Ownership -- statistics & numerical data
Ownership -- trends
Risk Management
Humans
United States

35. Medication errors in outpatient hematology and oncology clinics

Author(s):
Banasser, Ghadeer, author
Karpow, Celeste, author
Gaunt, Michael J., author
Grissinger, Matthew, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2017
Subject(s):
Ambulatory Care Facilities -- statistics & numerical data
Hematology
Medical Oncology
Medication Errors -- statistics & numerical data
Adrenal Cortex Hormones
Antineoplastic Agents
Colony-Stimulating Factors
Risk Management
Humans
Pennsylvania
United States

36. Warming blankets and patient harm

Author(s):
Feil, Michelle, author
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, December 2017
Subject(s):
Bedding and Linens -- adverse effects
Hyperthermia, Induced -- adverse effects
Medical Errors -- prevention & control
Medical Errors -- statistics & numerical data
Blister -- etiology
Body Temperature Changes
Burns -- etiology
Burns -- prevention & control
Equipment Failure
Risk Management
Humans
Pennsylvania
United States

37. Use of serological tests to reduce the risk of transmission of Trypanosoma cruzi infection in blood and blood components

Publication:
Silver Spring, MD : Center for Biologics Evaluation and Research, December 2017
Subject(s):
Blood Donors
Chagas Disease -- blood
Chagas Disease -- transmission
Disease Transmission, Infectious -- prevention & control
Donor Selection
Serologic Tests
Trypanosoma cruzi
Chagas Disease -- prevention & control
Risk Management
Humans
United States
United States. Department of Health and Human Services.
United States. Food and Drug Administration.

38. Adverse drug events with HYDROmorphone: how preventable are they?

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Analgesics, Opioid -- adverse effects
Dose-Response Relationship, Drug
Hydromorphone -- adverse effects
Medication Errors -- prevention & control
Narcotics -- adverse effects
Analgesics, Opioid -- administration & dosage
Analgesics, Opioid -- pharmacology
Central Nervous System Diseases -- chemically induced
Clinical Protocols -- standards
Drug Administration Schedule
Drug Overdose -- epidemiology
Drug Prescriptions
Hydromorphone -- administration & dosage
Hydromorphone -- pharmacology
Morphine -- administration & dosage
Narcotics -- administration & dosage
Narcotics -- pharmacology
Pain Management
Receptors, Opioid, mu -- agonists
Respiration Disorders -- chemically induced
Risk Management
Humans
United States

39. Beyond the bundle: reducing the risk of central line-associated bloodstream infections

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Catheterization, Central Venous -- adverse effects
Catheter-Related Infections -- prevention & control
Catheters, Indwelling -- adverse effects
Cross Infection -- prevention & control
Infection Control -- methods
Risk Management
Safety Management -- methods
Checklist
Equipment Contamination -- prevention & control
Evidence-Based Practice
Guideline Adherence
Outcome and Process Assessment (Health Care)
Humans
Pennsylvania
United States

40. Clostridium difficile infections in nursing homes

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Clostridium Infections -- prevention & control
Cross Infection -- prevention & control
Infection Control -- methods
Nursing Homes
Clostridium difficile
Clostridium Infections -- epidemiology
Clostridium Infections -- transmission
Evidence-Based Practice
Mandatory Reporting
Risk Factors
Risk Management
Humans
Pennsylvania
United States

41. Connecting remote cardiac monitoring issues with care areas

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2009
Subject(s):
Electrocardiography, Ambulatory -- methods
Monitoring, Physiologic -- methods
Telemetry -- methods
Clinical Alarms -- standards
Communication
Electrocardiography, Ambulatory -- instrumentation
Equipment Failure
Monitoring, Physiologic -- instrumentation
Practice Guidelines as Topic
Risk Management
Telemetry -- instrumentation
Humans
United States

43. Care at discharge: a critical juncture for transition to posthospital care

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2008
Subject(s):
Aftercare -- organization & administration
Case Management -- organization & administration
Continuity of Patient Care -- organization & administration
Patient Discharge -- standards
Appointments and Schedules
Medication Errors -- prevention & control
Medication Reconciliation -- methods
Patient Education as Topic
Risk Management
Humans
Pennsylvania
United States

44. Hemodialysis administration: strategies to ensure safe patient care

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Renal Dialysis -- adverse effects
Renal Dialysis -- methods
Safety
Accidental Falls -- prevention & control
Blood Coagulation
Clinical Protocols
Equipment Failure
Guideline Adherence
Kidney Failure, Chronic -- therapy
Medication Errors
Needles -- adverse effects
Risk Management
Humans
United States

46. Improving the safety of the blood transfusion process

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Blood Component Transfusion -- methods
Blood Transfusion -- methods
Medical Errors -- prevention & control
Quality Control
Safety Management
Automatic Data Processing
Blood Banks
Blood Component Transfusion -- adverse effects
Blood Group Incompatibility
Patient Identification Systems
Practice Guidelines as Topic
Risk Management
Transfusion Reaction
Humans
United States

47. Medication errors in the emergency department: need for pharmacy involvement?

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2011
Subject(s):
Emergency Service, Hospital -- organization & administration
Interprofessional Relations
Medication Errors -- prevention & control
Pharmacists
Pharmacy Service, Hospital -- organization & administration
Professional Role
Quality Improvement
Risk Management
Humans
United States

48. Managing patient access and flow in the emergency department to improve patient safety

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2010
Subject(s):
Efficiency, Organizational
Emergency Service, Hospital -- trends
Health Services Accessibility
Process Assessment (Health Care) -- standards
Safety Management -- organization & administration
Communication
Crowding
Emergency Service, Hospital -- utilization
Forecasting
Patient Satisfaction
Risk Management
Time Factors
Triage -- methods
Humans
United States

49. Increasing influenza and pneumonia vaccination rates in long-term care

Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2009
Subject(s):
Disease Outbreaks -- prevention & control
Immunization Programs -- utilization
Influenza Vaccines -- administration & dosage
Influenza, Human -- prevention & control
Long-Term Care
Pneumococcal Infections -- prevention & control
Pneumococcal Vaccines -- administration & dosage
Pneumonia, Pneumococcal -- prevention & control
Vaccination -- utilization
Adult
Aged
Frail Elderly
Health Knowledge, Attitudes, Practice
Health Personnel -- psychology
Influenza, Human -- mortality
Outcome Assessment (Health Care)
Patient Acceptance of Health Care
Pneumococcal Infections -- mortality
Program Development
Program Evaluation
Risk Management
Humans
United States