Issues
Current Issue
Castellucci M, Meyer H.20 years later: to Err is a Leadership Failure. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.;
Bendix J. Should doctors apologize for mistakes? Med Econ. November 10, 2109;96(21):17.;
The Associated Press. Flu shot mix-up at Oklahoma facility leaves 10 hospitalized. NBC News. November 8, 2019.;
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute care edition.
November 7, 2019;
Preseton E. Ignored, threatened, berated: After difficult childbirth experiences, new parents seek healing by speaking up. Stat News. November 8, 2019.;
Canadian Institute for Health Information. Canada continues to lag behind other OECD countries on measures of patient safety. Ottawa, ON: Canadian Institute for Health Information; 2019.;
Safe primary care – prescribing; Safe acute care – surgical complications and health care-associated infections, Safe acute care – obstetric trauma. Chapters In: Organisation for Economic Co-operation and Development. Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris: 2019.;
Vincent C, Staines A. Quality and Safety of Healthcare in Switzerland. Bern, Switzerland. Federal Department of Home Affairs, Federal Office of Public Health. 2019.;
Suicidal patient slips through the cracks. Oakbrook Terrace, IL: Joint Commission: October 2019.;
Aaronson E, Jansson P, Wittbold K, Flavin S, Borczuk P. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am J Emerg Med. Sep 6, 2019. ;
Eslami K, Aletayeb F, Aletayeb SMH, Kouti L, Hardani AK. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. Oct 22, 2019;19(1):365.;
Barbanti-Brodano G, Griffoni C, Halme J, Tedesco G, Terzi S, Bandiera S, Ghermandi R, Evangelisti G, Girolami M, Pipola V, Gasbarrini A, Falavigna A. Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them? Eur Spine J. Nov 6, 2019 .;
Williams S, Fiumara K, Kachalia A, Desai S. Closing the Loop with Ambulatory Staff on Safety Reports. The Joint Commission Journal on Quality and Patient Safety. Epub Nov 15, 2019;
Sheetz KH, Dimick JB, Englesbe MJ, Ryan AM. Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement. Health Aff. Nov, 2019;38(11):1858-1865.;
Melton KR, Timmons K, Walsh KE, Meinzen-Derr JK, Kirkendall E. Smart pumps improve medication safety but increase alert burden in neonatal care. BMC Med Inform Decis Mak. Nov 7, 2019;19(1):213.;
de Lima A, Osman BM, Shapiro FE. Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019. Curr Opin Anaesthesiol. Dec, 2019;32(6):749-755. ;
Bristol AA, Schneider CE, Lin SY, Brody AA. A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions. J Healthc Qual. Nov 6, 2019;
Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. Oct 17, 2019.;
Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan. Acad Med. Oct 29, 2019.;
Denson JL, Knoeckel J, Kjerengtroen S, Johnson R, McNair B, Thornton O, Douglas IS, Wechsler ME, Burke RE. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf. Nov 4, 2019.;
Past Issues
Castellucci M, Meyer H.20 years later: to Err is a Leadership Failure. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.;
Bendix J. Should doctors apologize for mistakes? Med Econ. November 10, 2109;96(21):17.;
The Associated Press. Flu shot mix-up at Oklahoma facility leaves 10 hospitalized. NBC News. November 8, 2019.;
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute care edition.
November 7, 2019;
Preseton E. Ignored, threatened, berated: After difficult childbirth experiences, new parents seek healing by speaking up. Stat News. November 8, 2019.;
Canadian Institute for Health Information. Canada continues to lag behind other OECD countries on measures of patient safety. Ottawa, ON: Canadian Institute for Health Information; 2019.;
Safe primary care – prescribing; Safe acute care – surgical complications and health care-associated infections, Safe acute care – obstetric trauma. Chapters In: Organisation for Economic Co-operation and Development. Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris: 2019.;
Vincent C, Staines A. Quality and Safety of Healthcare in Switzerland. Bern, Switzerland. Federal Department of Home Affairs, Federal Office of Public Health. 2019.;
Suicidal patient slips through the cracks. Oakbrook Terrace, IL: Joint Commission: October 2019.;
Aaronson E, Jansson P, Wittbold K, Flavin S, Borczuk P. Unscheduled return visits to the emergency department with ICU admission: A trigger tool for diagnostic error. Am J Emerg Med. Sep 6, 2019. ;
Eslami K, Aletayeb F, Aletayeb SMH, Kouti L, Hardani AK. Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatr. Oct 22, 2019;19(1):365.;
Barbanti-Brodano G, Griffoni C, Halme J, Tedesco G, Terzi S, Bandiera S, Ghermandi R, Evangelisti G, Girolami M, Pipola V, Gasbarrini A, Falavigna A. Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them? Eur Spine J. Nov 6, 2019 .;
Williams S, Fiumara K, Kachalia A, Desai S. Closing the Loop with Ambulatory Staff on Safety Reports. The Joint Commission Journal on Quality and Patient Safety. Epub Nov 15, 2019;
Sheetz KH, Dimick JB, Englesbe MJ, Ryan AM. Hospital-Acquired Condition Reduction Program Is Not Associated With Additional Patient Safety Improvement. Health Aff. Nov, 2019;38(11):1858-1865.;
Melton KR, Timmons K, Walsh KE, Meinzen-Derr JK, Kirkendall E. Smart pumps improve medication safety but increase alert burden in neonatal care. BMC Med Inform Decis Mak. Nov 7, 2019;19(1):213.;
de Lima A, Osman BM, Shapiro FE. Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019. Curr Opin Anaesthesiol. Dec, 2019;32(6):749-755. ;
Bristol AA, Schneider CE, Lin SY, Brody AA. A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions. J Healthc Qual. Nov 6, 2019;
Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. Oct 17, 2019.;
Singh H, Upadhyay DK, Torretti D. Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan. Acad Med. Oct 29, 2019.;
Denson JL, Knoeckel J, Kjerengtroen S, Johnson R, McNair B, Thornton O, Douglas IS, Wechsler ME, Burke RE. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf. Nov 4, 2019.;
Tawfik DS, Thomas EJ, Vogus TJ, Liu JB, Sharek PJ, Nisbet CC, Lee HC, Sexton JB, Profit J. Safety climate, safety climate strength, and length of stay in the NICU. BMC Health Serv Res. Oct 22, 2019;19(1):738.;
Mackenzie CF, Shackelford SA, Tisherman SA, Yang S, Puche A, Elster EA, Bowyer MW. Critical errors in infrequently performed trauma procedures after training. Surgery. Nov, 2019;166(5):835-843.;
Dharmarajan TS, Choi H, Hossain N, Munasinghe U, Lakhi F, Lourdusamy D, Onuoha S, Murakonda P, Skokowska-Lebelt A, Kanagala M, Russell RO. Deprescribing as a Clinical Improvement Focus. J Am Med Dir Assoc. Oct 28, 2019.;
Klasen JM, Driessen E, Teunissen PW, Lingard LA. 'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety. BMJ Qual Saf. Nov 8, 2019.;
Hu Y-Y, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, Potts JR, Buyske J, Hoyt DB, Nasca TJ, Bilimoria KY. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med. Oct , 2019; 381(18):1741-1752. ;
Keller SC, Cosgrove SE, Arbaje AI, Chang RH-E, Krosche A, Williams D, Gurses AP. Roles and Role Ambiguity in Patient- and Caregiver-Performed Outpatient Parenteral Antimicrobial Therapy. Jt Comm J Qual Patient Saf. 2019;45(11):763-771.;
Hall AJ, Toner NS, Bhatt PM. The introduction of a Neurosurgical Postoperative Checklist improved quality of care and patient safety. Br J Neurosurg. Oct 2019 [epub April 2019];33(5):495-499.;
Krishnamohan N, Maitra I, Shetty VD. The surgical ward round checklist: Improving patient safety and clinical documentation. Journal of Multidisciplinary Healthcare. Sep 2019;12:789-794.;
Connors CA, Dukhanin V, March AL, Parks JA, Norvell M, Wu AW. Peer support for nurses as second victims: Resilience, burnout, and job satisfaction. Journal of Patient Safety and Risk Management.0(0):2516043519882517.;
Young IJB, Luz S, Lone N. A systematic review of natural language processing for classification tasks in the field of incident reporting and adverse event analysis. Int J Med Inform. Oct 05, 2019;132:103971.;
The Peoples Pharmacy. Show 1186: What Happens When Doctors Make Diagnostic Errors? National Public Radio. October 24, 2019.;
Boston Children's Hospital; Institute for Professionalism and Ethical Practice. Deep dive into error disclosure. December 10, 2019, 12:00-2:00 pm (Eastern).;
Cooper J. Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad. Anesthesiology 2019. October 19th, 2019; Orlando, FL.;
Sutcliffe K. The Health Care Industry Needs to Be More Honest About Medical Errors. Nov 5, 2019. Retrieved 11/12/19;
Sexton J, Schweber N. The wrong goodbye. ProPublica. October 31, 2019.;
AHA Team Training. TeamSTEPPS Next Steps Workshop. March 4–5, 2020; University of Washington, Seattle, WA.;
20 Years After “To Err is Human”, Leapfrog Hospital Safety Grades Prove Transparency Can Save Lives. 2019;
Center for Patient and Professional Advocacy. Promoting Professionalism: Addressing Behaviors that Undermine a Culture of Safety. December 6-7, 2019, Kimpton Aertson Hotel, Nashville, TN.;
States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171 (7_Supplement); 2019 (7_Supplement)
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. BMJ Open. Sep 12, 2019;9(9):e028280.;
Blenkinsopp J, Snowden N, Mannion R, Powell M, Davies H, Millar R, McHale J. Whistleblowing over patient safety and care quality: a review of the literature. Journal of health organization and management. Sept, 2019;33(6):737-756.;
Hajibandeh S, Hajibandeh S, Satyadas T. Impact of weekend effect on postoperative mortality in patients undergoing emergency General surgery procedures: Meta-analysis of prospectively maintained national databases across the world. Surgeon. Oct 18, 2019.;
Woo SA, Cragg A, Wickham ME, Villanyi D, Scheuermeyer F, Hau JP, Hohl CM. Preventable adverse drug events: Descriptive epidemiology. Br J Clin Pharmacol. Oct 21, 2019.;
Carson-Stevens A, Campbell S, Bell BG, Cooper A, Armstrong S, Ashcroft D, Boyd M, Prosser Evans H, Mehta R, Sheehan C, Sheikh A, Avery A. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Fam Pract. Oct 4, 2019;20(1):134.;
Archer S, Thibaut BI, Dewa L, Ramtale C, D'Lima D, Simpson A, Murray K, Adam S, Darzi A. Barriers and facilitators to incident reporting in mental healthcare settings: a qualitative study. J Psychiatr Ment Health Nurs. Oct 22, 2019.;
Etherington N, Usama A, Patey AM, Trudel C, Przybylak-Brouillard A, Presseau J, Grimshaw JM, Boet S. Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. BMJ Open Qual. Aug, 2019;8(3):e000686.;
O’Connell D. Disclosure after adverse medical outcomes: A multidimensional challenge. J Clin Outcomes Manag. 2019;26(5):213-218.;
Mendu ML, Lu Y, Petersen A, Tellez MG, Beloff J, Fiumara K, Kachalia A. Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt. BMJ Quality & Safety. Oct 24, 2019;24:24.;
Donner-Banzhoff N, Muller B, Beyer M, Haasenritter J, Seifart C. Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences. Diagnosis (Berl). Oct 24, 2019.;
Stankovic C, Wolff M, Chang TP, Macias C. A National Patient Safety Curriculum in Pediatric Emergency Medicine. Pediatr Emerg Care. Aug, 2019;35(8):519-521.;
Drug Shortage Task Force. Drug Shortages: Root Causes and Potential Solutions. US Food and Drug Administration: 2019;
Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge. Healthcare Safety Investigation Branch. Farnborough, UK: 2019.;
Proactive prevention of maternal death from maternal hemorrhage. Quick Safety. October 2019;51:1-3.;
Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets. ISMP Medication Safety Alert! Acute care edition. October 24, 2019.;
Neighmond P. Working Americans are getting less sleep, especially those who save our lives. Shots. National Pubic Radio. October 28, 2019.;
Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction. Plymouth Meeting, PA: 2019.;
Accreditation Council for Graduate Medical Education, American College of Surgeons, Association of Program Directors in Surgery and American Board of Surgery.;
NAM Action Collaborative on Clinician Well-Being and Resilience. Case Study Webinar Series on Clinician Burnout: The Ohio State University. National Academies of Medicine.;
Cullen SW, Xie M, Vermeulen JM, Marcus SC. Comparing Rates of Adverse Events and Medical Errors on Inpatient Psychiatric Units at Veterans Health Administration and Community-based General Hospitals. Med Care. Nov, 2019;57(11):913-920.;
Yeh J, Wilson R, Young L, Pahl L, Whitney S, Dellsperger KC, Schafer PE. Team-Based Intervention to Reduce the Impact of Nonactionable Alarms in an Adult Intensive Care Unit. Journal of Nursing Care Quality. Sep., 2019;
Axtell AL, Moonsamy P, Melnitchouk S, Jassar AS, Villavicencio MA, D'Alessandro DA, Tolis G, Cameron DE, Sundt TM. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J Thorac Cardiovasc Surg. Sep 11, 2019.;
Havaei F, MacPhee M, Dahinten VS. The effect of nursing care delivery models on quality and safety outcomes of care: A cross‐sectional survey study of medical‐surgical nurses. Journal of Advanced Nursing (John Wiley & Sons, Inc). Oct, 2019 [epub April, 2019];75(10):2144-2155.;
Ebbens MM, Errami H, Moes D, van den Bemt P, van der Boog PJM, Gombert-Handoko KB. Prevalence of medication transfer errors in nephrology patients and potential risk factors. Eur J Intern Med. Oct 09, 2019;09:09.;
Rhudy LM, Johnson MR, Krecke CA, Keigley DS, Schnell SJ, Maxson PM, McGill SM, Warfield KT. Change‐of‐Shift Nursing Handoff Interruptions: Implications for Evidence‐Based Practice. Worldviews Evid Based Nurs. Oct, 2019 [epub July, 2019];16(5):362-370.;
Schwappach DLB, Niederhauser A. Speaking up about patient safety in psychiatric hospitals - a cross-sectional survey study among healthcare staff. Int J Ment Health Nurs. Oct 14, 2019.;
O’Reilly-Shah VN, Melanson VG, Sullivan CL, Jabaley CS, Lynde GC. Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study. BMC anesthesiology. 2019 Dec;19(1):1-8.;
Hazen ACM, Zwart DLM, Poldervaart JM, de Gier JJ, de Wit NJ, de Bont AA, Bouvy ML. Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care. Fam Pract. Oct 8, 2019;36(5):544-551.;
Abdallah W, Johnson C, Nitzl C, Mohammed MA. Organizational learning and patient safety: hospital pharmacy settings. Journal of Health Organization and Management. Sep 5, 2019; 33 (6), 695-713.;
Ganguli I, Simpkin AL, Lupo C, Weissman A, Mainor AJ, Orav EJ, Rosenthal MB, Colla CH, Sequist TD. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Network Open. 2019 Oct 2;2(10):e1913325-.;
de Santana Lemos C, de Brito Poveda V. Adverse Events in Anesthesia: An Integrative Review. J Perianesth Nurs. Oct, 2019 [epub April, 2019]; 34(5):978-99;
Bailey M. ‘Fear of falling’: How hospitals do even more harm by keeping patients in bed. Kaiser Health News. October 17, 2019.;
McLean K. My patient almost died from a mistake I made. I apologized and it changed my life. Huffington Post. October 16, 2019.;
Rabin RC. Faced with a drug shortfall, doctors scramble to treat children with cancer. New York Times. October 14, 2019.;
Same Day Surgery in the US; Findings of Two Inaugural Leapfrog Surveys 2019. Washington DC: Leapfrog Group; 2019.;
Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital setting. Am J Health Syst Pharm. Sept 16, 2019;76(19):1481-1491.;
National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press; 2019.;
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm, US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and Investigations. 116th Cong, 1st Sess (2019).;
FDA Funding Available for Research Aimed at Reducing Preventable Harm from Medication. Silver Spring, MD; US Food and Drug Administration: October 4, 2019.;