Issues
Current Issue
Businger AC, Fuller TE, Schnipper JL, Rossetti SC, Schnock KO, Rozenblum R, Dalal AK, Benneyan J, Bates DW, Dykes PC. Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center. J Am Med Inform Assoc. 2019 Dec 3.;
Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. JAMA Pediatr [epub ahead of print].;
Gilleland J, Bayfield D, Bayliss A, et al. Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital. BMJ Open Qual. 2019;8(4):e000763. doi: 10.1136/bmjoq-2019-000763.;
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019 Dec 4;19(1):77. doi: 10.1186/s12873-019-0289-3;
Ferguson BA, Lauriski DR, Huecker M, Wichmann M, Shreffler J, Shoff H. Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care. J Emerg Med. 2019 Dec 6 [epub ahead of print].;
McLeod PL, Cunningham QW, DiazGranados D, et al. Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine. Health Care Manage Rev. 2019 Dec 3 [epub ahead of print].;
Meyers JS, Lane-Fall MB, Perfetti AR, et al. Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety. BMJ Qual Saf. 2019 Dec 3 [epub ahead of print]. doi: 10.1136/bmjqs-2019-010204.;
Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents' error recovery strategies. Am J Surg. 2019 Nov 19 [epub ahead of print]. doi: 10.1016/j.amjsurg.2019.11.013.;
Thomas JJ, Yaster M, Guffey P. The Use of Patient Digital Facial Images to Confirm Patient Identity in a Children's Hospital's Anesthesia Information Management System. Jt Comm J Qual Patient Saf. 2019 Dec 3 [epub ahead of print]. pii: S1553-7250(19)30442-8. doi: 10.1016/j.jcjq.2019.10.007.;
Machen S, Jani Y, Turner S, Marshall M, Fulop NJ. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Qual Health Care. 2019 Dec 10. [Epub ahead of print].;
Sauro K, Ghali WA, Stelfox HT. Measuring safety of healthcare: an exercise in futility? BMJ Qual Saf. 2019 Dec 3 [epub ahead of print]. doi: 10.1136/bmjqs-2019-009824.;
Advancing safety with closed-loop communication of test results. Quick Safety. December 2019;52:1-3.;
Kukielka E, Gipson KR, Jones R. A brief analysis of telemetry–related events. Patient Safety. 2019;1(2):9. doi:10.33940/biomed/2019.12.4.;
Szabo L. Artificial intelligence Is rushing into patient care - and could raise risks. Scientific American and Kaiser Health News. December 24, 2019.;
Lintern S. NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes. December 25, 2019.;
Rockville, MD: Agency for Healthcare Research and Quality. Health Services Research Priorities for Improving Diagnostic Safety and Quality. Special Emphasis Notice (SEN). December 27, 2019. Publication No. NOT-HS-20-004.;
Electronic Health Record (EHR) Safety and Usability: See What We Mean. MedStar Health National Center for Human Factors in Healthcare.;
Institute for Healthcare Improvement and British Medical Journal. The International Forum on Quality and Safety in Healthcare. April 28-30, 2020, Bella Center Copenhagen, Copenhagen, Denmark.;
Understanding SOPS Surveys: A Primer for New Users. Agency for Healthcare Research and Quality (AHRQ). February 19, 2020.;
Past Issues
Businger AC, Fuller TE, Schnipper JL, Rossetti SC, Schnock KO, Rozenblum R, Dalal AK, Benneyan J, Bates DW, Dykes PC. Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center. J Am Med Inform Assoc. 2019 Dec 3.;
Bonafide CP, Miller JM, Localio AR, et al. Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit. JAMA Pediatr [epub ahead of print].;
Gilleland J, Bayfield D, Bayliss A, et al. Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital. BMJ Open Qual. 2019;8(4):e000763. doi: 10.1136/bmjoq-2019-000763.;
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019 Dec 4;19(1):77. doi: 10.1186/s12873-019-0289-3;
Ferguson BA, Lauriski DR, Huecker M, Wichmann M, Shreffler J, Shoff H. Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care. J Emerg Med. 2019 Dec 6 [epub ahead of print].;
McLeod PL, Cunningham QW, DiazGranados D, et al. Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care medicine. Health Care Manage Rev. 2019 Dec 3 [epub ahead of print].;
Meyers JS, Lane-Fall MB, Perfetti AR, et al. Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety. BMJ Qual Saf. 2019 Dec 3 [epub ahead of print]. doi: 10.1136/bmjqs-2019-010204.;
Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents' error recovery strategies. Am J Surg. 2019 Nov 19 [epub ahead of print]. doi: 10.1016/j.amjsurg.2019.11.013.;
Thomas JJ, Yaster M, Guffey P. The Use of Patient Digital Facial Images to Confirm Patient Identity in a Children's Hospital's Anesthesia Information Management System. Jt Comm J Qual Patient Saf. 2019 Dec 3 [epub ahead of print]. pii: S1553-7250(19)30442-8. doi: 10.1016/j.jcjq.2019.10.007.;
Machen S, Jani Y, Turner S, Marshall M, Fulop NJ. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Qual Health Care. 2019 Dec 10. [Epub ahead of print].;
Sauro K, Ghali WA, Stelfox HT. Measuring safety of healthcare: an exercise in futility? BMJ Qual Saf. 2019 Dec 3 [epub ahead of print]. doi: 10.1136/bmjqs-2019-009824.;
Advancing safety with closed-loop communication of test results. Quick Safety. December 2019;52:1-3.;
Kukielka E, Gipson KR, Jones R. A brief analysis of telemetry–related events. Patient Safety. 2019;1(2):9. doi:10.33940/biomed/2019.12.4.;
Szabo L. Artificial intelligence Is rushing into patient care - and could raise risks. Scientific American and Kaiser Health News. December 24, 2019.;
Lintern S. NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes. December 25, 2019.;
Rockville, MD: Agency for Healthcare Research and Quality. Health Services Research Priorities for Improving Diagnostic Safety and Quality. Special Emphasis Notice (SEN). December 27, 2019. Publication No. NOT-HS-20-004.;
Electronic Health Record (EHR) Safety and Usability: See What We Mean. MedStar Health National Center for Human Factors in Healthcare.;
Institute for Healthcare Improvement and British Medical Journal. The International Forum on Quality and Safety in Healthcare. April 28-30, 2020, Bella Center Copenhagen, Copenhagen, Denmark.;
Understanding SOPS Surveys: A Primer for New Users. Agency for Healthcare Research and Quality (AHRQ). February 19, 2020.;
Delio J, Catalanotti JS, Marko K, Paul C, Taffel M, Ho G, Berger J. Integrating adverse event reporting into a free-text mobile application used in daily workflow increases adverse event reporting by physicians. Am J Med Qual. 2019 Dec 4:1062860619891995. doi: 10.1177/1062860619891995. [Epub ahead of print];
Koers L, van Haperen M, Meijer CGF, van Wandelen SBE, Waller E, Dongelmans D, Boermeester MA, Hermanides J, Preckel B. Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. JAMA Surg. 2019 Nov 27:e194704. doi: 10.1001/jamasurg.2019.4704. [Epub ahead of print];
Scott J, Dawson P, Heavey E, et al. Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients? [published online ahead of print, 2019 Nov 26]. J Patient Saf. 2019;10.1097/PTS.0000000000000654.;
Carayon P, Hoonakker P, Hundt AS, Salwei M, Wiegmann D, Brown RL, Kleinschmidt P, Novak C, Pulia M, Wang Y, Wirkus E, Patterson B. Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. BMJ Qual Saf. 2019 Nov 27. pii: bmjqs-2019-009857. doi: 10.1136/bmjqs-2019-009857. [Epub ahead of print];
Manges K, Groves PS, Farag A, Peterson R, Harton J, Greysen SR. A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge. BMJ Qual Saf. 2019 Nov 27. pii: bmjqs-2019-009716. doi: 10.1136/bmjqs-2019-009716. [Epub ahead of print].;
Ottosen MJ, Engebretson J, Etchegaray J, Arnold C, Thomas EJ. An ethnography of parents' perceptions of patient safety in the neonatal intensive care unit. Adv Neonatal Care. 2019 Dec;19(6):500-508. doi: 10.1097/ANC.0000000000000657.;
Yorio PL, Edwards J, Hoeneveld D. Safety culture across cultures. Saf Sci. 2019 Dec;120:402-410. doi: 10.1016/j.ssci.2019.07.021.;
O'Mahony D. STOPP/START criteria for potentially inappropriate medications/ potential prescribing omissions in older people: origin and progress. Expert Rev Clin Pharmacol. 2019 Nov 30:1-8. doi: 10.1080/17512433.2020.1697676. [Epub ahead of print];
Siegal D, Swift J, Forget J, Slowick T. J Healthc Risk Manag. Harnessing the power of medical malpractice data to improve patient care. 2019 Nov 24. doi: 10.1002/jhrm.21393. [Epub ahead of print];
Wu AW, Dzau VJ. What can patient safety teach us about clinician burnout? Ann Intern Med. 2019 Dec 10. doi: 10.7326/M19-2397. [Epub ahead of print].;
Khorana MM, Khorana AA. Measuring quality. JAMA. 2019 Dec 3;322(21):2077-2078. doi: 10.1001/jama.2019.18730.;
Improving Quality of Care and Patient Outcomes During Care Transitions (R01). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ), Program announcement PA-20-068. December 6, 2019.;
IHI Lucian Leape Institute. Moving Measurement into Action: Global Principles for Measuring Patient Safety. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar; December 2019.;
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem Association of Pennsylvania. Q3 Health Innovation Partners.;
Institute for Safe Medication Practices Canada. Med Safety Exchange Webinar Series. January 15, 2020; 12:00-1:00 PM (Eastern).;
Centers for Disease Control and Prevention and the Society for Healthcare Epidemiology of America. The 6th Decennial International Conference on Healthcare Associated Infections. March 26-30, 2020, Atlanta Marriott Marquis, Atlanta, GA.;
Halamek LP, ed. Patient Safety. Semin Perinatol. 2019;43(8):151172-151182.;
Huang CH, Umegaki H, Watanabe Y, Kamitani H, Asai A, Kanda S, Nomura H, Kuzuya M. Potentially inappropriate medications according to STOPP-J criteria and risks of hospitalization and mortality in elderly patients receiving home-based medical services. PLoS One. 2019;14(2).;
Kravet S, Bhatnagar M, Dwyer M, Kjaer K, Evanko J, Singh H. Prioritizing Patient Safety Efforts in Office Practice Settings. Journal of patient safety. 2019;15(4):e98-e101.;
Gibson B, Butler J, Schnock K, Bates D, Classen D. Design of a safety dashboard for patients. Patient Educ Couns. Nov 9, 2019.;
Appelbaum N, Clarke J, Feather C, Franklin B, Sinha R, Pratt P, Maconochie I, Darzi A. Medication errors during simulated paediatric resuscitations: a prospective, observational human reliability analysis. BMJ Open. Nov 25, 2019;9(11):e032686.;
Levine KJ, Carmody M, Silk K. The Influence of Organizational Culture, Climate and Commitment on Speaking Up About Medical Errors. J Nurs Manag. Nov 16, 2019.;
Donnelly EA, Bradford P, Davis M, Hedges C, Socha D, Morassutti P. Fatigue and Safety in Paramedicine. Cjem. Nov, 2019;21(6):762-765.;
Martín MÁP, García MM, Silveira ED, Martin-Aragón S, Vicedo TB. Medication errors in the care transition of trauma patients. Eur J Clin Pharmacol. 2019;75(12):1739-1746.;
Sanduende-Otero Y, Villalon-Coca J, Romero-Garcia E, Diaz-Cambronero O, Barach P, Arnal-Velasco D. Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system. Br J Anaesth. Nov 25, 201;
Rozenblum R, Rodriguez-Monguio R, Volk LA, Forsythe KJ, Myers S, McGurrin M, Williams DH, Bates DW, Schiff G, Seoane-Vazquez E. Using a Machine Learning System to Identify and Prevent Medication Prescribing Errors: A Clinical and Cost Analysis Evaluation. The Joint Commission Journal on Quality and Patient Safety. 2019/11/27/, 2019.;
Jones N.; 2016 Jan 11 [Epub ahead of print]
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, Paananen J, Franklin BD, Rafferty AM. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incident Report Data. Journal of Nursing Scholarship. 2019 Nov 25.;
Arditi L. EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived. Peoples Public Radio. December 3, 2019.;
Garcia-Navarro L. As university hospital hounds debtors, doctors say it's doing harm. Weekend Edition Sunday. December 1, 2019.;
Lintern S. ‘Largest maternity scandal in NHS history’: Dozens of mothers and babies died on wards of hospital trust, leaked report reveals. The Independent. November 18, 2019.;
Tirrell M, Taylor H. Mounting drug shortages delay treatments for patients with bladder cancer. CNBC. November 27, 2019.;
Karlamangla S. Their kids died on the psych ward. They were far from alone, a Times investigation found. Los Angeles Times. December 1, 2019.;
Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol. 2019;75(12):1645-1657.;
Wears R, Sutcliffe K. Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. New York, NY: Oxford University Press; 2019.;
Millenson ML. The lurking danger in the “business case” for patient safety. Health Affairs Blog. December 2, 2019.;
American College of Healthcare Executives. Congress on Healthcare Leadership, Hyatt Regency—Chicago, Chicago, IL, March 23–26, 2020.;
Herzberg S, Hansen M , Schoonover A, Skarica B, McNulty J, Harrod T, Snowden JM, Lambert W, Guise JM. Association between measured teamwork and medical errors: an observational study of prehospital care in the USA. BMJ Open. 2019;9(10).;
Leamy K, Thompson J, Mitra B. Awareness of diagnosis and follow up care after discharge from the Emergency Department. Australas Emerg Care. Dec, 2019;22(4):221-226.;
Stocks SJ, Alam R, Bowie P, Campbell S, de Wet C, Esmail A, Cheraghi-Sohi S. Never Events in UK General Practice: A Survey of the Views of General Practitioners on Their Frequency and Acceptability as a Safety Improvement Approach. Journal of Patient Safety. 2019;15(4):334-342.;
Orejuela Zapata JF. Impact of an educational initiative targeting non-radiologist staff on overall notification times of critical findings in radiology. Emerg Radiol. Dec, 2019 [epub July, 2019];26(6):593-600.;
Pereira -Lima K, Mata DA, Loureiro SR, Crippa JA, Bolsoni LM, Sen S. Association Between Physician Depressive Symptoms and Medical Errors: A Systematic Review and Meta-analysis. JAMA Network Open. 2019;2(11):e1916097;
Alghamdi AA, Keers RN, Sutherland A, Ashcroft DM. Prevalence and Nature of Medication Errors and Preventable Adverse Drug Events in Paediatric and Neonatal Intensive Care Settings: A Systematic Review. Drug Saf. Dec, 2019;42(12):1423-1436.;
Li R, Zaidi STR, Chen T, Castelino R. Effectiveness of interventions to improve adverse drug reaction reporting by healthcare professionals over the last decade: A systematic review. Pharmacoepidemiol Drug Saf. Nov 14, 2019.;
Graham C, Reid S, Lord TC, Taylor KH. The evolution of patient safety procedures in an oral surgery department. Br Dent J. 2019;226(1):32-38.;
Allhoff F. Medical Error and Moral Luck. Kennedy Inst Ethics J. 2019;29(3):187-203.;
Chassin M, Foster N. Patient safety leader reflects on ‘To Err is Human’ report. November 13, 2019.;
Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. Environmental Scan. Washington DC; National Quality Forum: October 28, 2019.;
Gilbert D, Gutman D. Before mea culpa, Children’s was confident its air systems weren’t source of infection. Seattle Times. Nov. 26, 2019.;
Glicksman E. Your diagnosis was wrong. Could doctor bias have been a factor? Washington Post. November 17, 2019.;
Agency for Healthcare Research and Quality. Toolkit To Improve Antibiotic Use in Acute Care Hospitals. 2019.;