Selected Serious Events: References

Association for Safe Aseptic Practice (The-ASAP). Aseptic non touch technique: The ANTT clinical practice framework. London; The-ASAP; 2015. http://www2.nphs.wales.nhs.uk:8080/WHAIPDocs.nsf/61c1e930f9121fd080256f2a004937ed/e4528983f2eddd3a80257f10003dd2f3/$FILE/ANTT%20Framework%20v4.0.pdf

Canadian Hemophilia Society. Commemoration of the tainted blood tragedy. Retrieved from website April 2021. https://www.hemophilia.ca/commemoration-of-the-tainted-blood-tragedy/

Canadian Institute for Health Information (CIHI), Canadian Patient Safety Institute. Measuring patient harm in Canadian hospitals. Ottawa, ON: CIHI; 2016. https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC3312

Health Quality Ontario, Canadian Patient Safety Institute (CPSI). Never events for hospital care in Canada: Safer care for patients. Edmonton, AB: CPSI; 2015.

Healthcare Insurance Reciprocal of Canada (HIROC). Risk reference sheet: Unnecessary/obsolete procedures. Toronto, ON: HIROC; 2016. https://www.hiroc.com/getmedia/45537195-5d6d-45c7-8c7d-87132c6e15df/30_Unnecessary-Obsolete-Procedures.pdf.aspx?ext=.pdf (accessed January 2018; inactive June 2021)

Healthcare Insurance Reciprocal of Canada (HIROC). Risk reference sheet: Surgical inadequate sterility. Toronto, ON: HIROC; 2012. https://www.hiroc.com/getmedia/ef3098cb-9026-41c0-8c5e-dc2ce1a5891f/29-Inadequate-Sterility-Risk-Reference-Sheet.pdf.aspx?ext=.pdf (accessed January 2018; inactive June 2021)

Healthcare Insurance Reciprocal of Canada (HIROC). Risk reference sheet: Wrong patient/site/procedure. Toronto, ON: HIROC; 2016. 
https://www.hiroc.com/getmedia/22f0e351-4066-4c39-84d5-1560f20084d1/31_Wrong-Patient-Site-Procedure.pdf.aspx?ext=.pdf (accessed January 2018; inactive June 2021)

Institute for Healthcare Improvement (IHI). How-to guide: Prevent harm from high-alert medications. Cambridge, MA: IHI; 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedications.aspx

Health Standards Organization Leading Practices. Utilization of safety crosses as a quality management tool in sterile processing department Markham Stouffville Hospital Corporation. Ottawa, ON: Health Standards Organization; 2013.  https://healthstandards.org/leading-practice/utilization-of-safety-crosses-as-a-quality-management-tool-in-sterile-processing-department/

Minnesota Department of Health. Adverse health events in Minnesota: Tenth annual public report.  Minnesota Department of Health; 2014. https://www.health.state.mn.us/facilities/patientsafety/adverseevents/docs/2014ahereport.pdf

Mulloy DF, Huges RG. Chapter 36: Wrong-site surgery: A preventable medical error. In: Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.  https://www.ncbi.nlm.nih.gov/books/NBK2678/pdf/Bookshelf_NBK2678.pdf

National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Commonwealth of Australia; 2019.
            https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019

Öçgüder A., Medvecky M. (2018) Failure Modes of Knots and Sutures. In: Akgun U., Karahan M., Randelli P., Espregueira-Mendes J. (eds) Knots in Orthopedic Surgery. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-56108-9_5

Ontario Agency for Health Protection and Promotion, Public Health Ontario, Provincial Infectious Diseases Advisory Committee, Infection Prevention and Control. Best practices for cleaning, disinfection, and sterilization of medical equipment/devices in all health care settings (3^rd ed.) Toronto, ON: Queen's Printer for Ontario; 2013. http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf

Pennsylvania Patient Safety Authority. Distractions in the operating room. Pa Patient Saf Advis. 2014; 11 (2): 45-52. http://patientsafety.pa.gov/ADVISORIES/Pages/201406_45.aspx

Pennsylvania Patient Safety Authority. Patient safety topics – Wrong Site Surgery. 2018 http://patientsafety.pa.gov/pst/Pages/Wrong%20Site%20Surgery/hm.aspx?psapst=Wrong-Site%20Surgery

Public Health Agency of Canada (PHAC). Routine practices and additional precautions for preventing the transmission of infection in healthcare settings. Ottawa, ON: PHAC; 2012. http://publications.gc.ca/collections//collection_2013/aspc-phac/HP40-83-2013-eng.pdf

Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention (CDC); 2007. http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf

Sitzwohl C, Langheinrich A, Schober A, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010; 341: c5943. doi: 10.1136/bmj.c5943. https://www.bmj.com/content/341/bmj.c5943.long