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What’s New this Week | 02/01/12
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The latest annotated links to patient safety literature, news, and more.
JOURNAL ARTICLE
 System-related interventions to reduce diagnostic errors: a narrative review. Singh H, Graber ML, Kissam SM, et al. BMJ Qual Saf. 2012;21:160-170.
Finding and fixing diagnosis errors: can triggers help? Schiff GD. BMJ Qual Saf. 2012;21:89-92.
Patients' attitudes towards patient involvement in safety interventions: results of two exploratory studies. Davis RE, Sevdalis N, Pinto A, Darzi A, Vincent CA. Health Expect. 2011 Dec 12; [Epub ahead of print].
A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Patanwala AE, Sanders AB, Thomas MC, et al. Ann Emerg Med. 2012 Jan 4; [Epub ahead of print].
Medication administration errors for older people in long-term residential care. Szczepura A, Wild D, Nelson S. BMC Geriatr. 2011;11:82.
Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs. Ranchon F, Salles G, Späth HM, et al. BMC Cancer. 2011;11:478.
Effective discharge communication in the emergency department. Samuels-Kalow ME, Stack AM, Porter SC. Ann Emerg Med. 2012 Jan 4; [Epub ahead of print].
Rapid response systems: identification and management of the "prearrest state." McCurdy MT, Wood SL. Emerg Med Clin North Am. 2012;30:141-152.
Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST). Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012 Jan 9; [Epub ahead of print].
SPECIAL OR THEME ISSUE
 Elderly Falls. J Safety Res. 2011;42:415-542.
TOOLS/TOOLKIT
 AHRQ Quality Indicators Toolkit for Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; January 2012.
MEETING/CONFERENCE
 Patient Safety Resource Seminar: Librarians on the Front Lines. Greater Midwest Region National Network of Libraries of Medicine. February 20–March 30, 2012.

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Also of Note...
Adverse Health Events in Minnesota: Eighth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2012.
AHRQ 2011 Annual Conference.  Agency for Healthcare Research and Quality. September 2011.
An Introduction to AHRQ PSNet
Robert M. Wachter, MD
Editor, AHRQ PSNet
Patient Safety Primers
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Learn about key concepts in patient safety with our primers

• Never Events

• Medication Reconciliation

• Handoffs and Signouts

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Did You Know?
Most diagnostic errors occurred during the testing phase