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The Collection
Annotated links to patient safety literature, news, and other resources.
The 25 most-viewed-items, updated weekly.
  1. STUDY 
    Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.
    Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-1512.
  2. STUDY
    Evaluation of the effectiveness of a surgical checklist in Medicare patients.
    Reames BN, Scally CP, Thumma JR, Dimick JB. Med Care. 2015;53:87-94.
  3. STUDY
    Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.
    McAllister C, Leykum LK, Lanham H, et al. J Hosp Med. 2014;9:764-771.
  4. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  5. MULTI-USE WEBSITE
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2015.
  6. REVIEW
    The use of technology for urgent clinician to clinician communications: a systematic review of the literature.
    Nguyen C, McElroy LM, Abecassis MM, Holl JL, Ladner DP. Int J Med Inform. 2015;84:101-110.
  7. AUDIOVISUAL 
    Old and overmedicated: the real drug problem in nursing homes.
    Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
  8. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  9. REVIEW
    Discussing harm-causing errors with patients: an ethics primer for plastic surgeons.
    Vercler CJ, Buchman SR, Chung KC. Ann Plast Surg. 2014 May 14; [Epub ahead of print].
  10. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  11. COMMENTARY
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  12. BOOK/REPORT
    2014 Annual Benchmarking Report: Malpractice Risks in the Diagnostic Process.
    Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
  13. STUDY
    Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.
    Chassin MR, Mayer C, Nether K. Jt Comm J Qual Patient Saf. 2015;41:4-12.
  14. STUDY
    Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.
    Pronovost PJ, Armstrong CM, Demski R, et al. Acad Med. 2014 Dec 16; [Epub ahead of print].
  15. STUDY
    Association of the 2011 ACGME resident duty hour reforms with mortality and readmissions among hospitalized Medicare patients.
    Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-2373.
  16. STUDY
    Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.
    Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-2384.
  17. STUDY
    Developing and evaluating the success of a family activated medical emergency team: a quality improvement report.
    Brady PW, Zix J, Brilli R, et al. BMJ Qual Saf. 2014 Dec 16; [Epub ahead of print].
  18. BOOK/REPORT
    The Public's Views on Medical Error in Massachusetts.
    Boston, MA: Harvard School of Public Health; December 2014.
  19. BOOK/REPORT
    Improving the Emergency Department Discharge Process.
    Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.
  20. COMMENTARY
    Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.
    Reilly JB, Bennett N, Fosnocht K, et al. Acad Med. 2014 Nov 25; [Epub ahead of print].
  21. COMMENTARY
    Pharmacist-managed inpatient discharge medication reconciliation: a combined onsite and telepharmacy model.
    Keeys C, Kalejaiye B, Skinner M, et al. Am J Health Syst Pharm. 2014;71:2159-2166.
  22. COMMENTARY
    A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy.
    Boyd M. J Eval Clin Pract. 2014 Nov 13; [Epub ahead of print].
  23. COMMENTARY
    Building a community engagement approach for patient safety improvement.
    Gooden R, Syed SB, Rutter P, Hightower JD, Kelley E. Community Dev J. 2014;49:631-641.
  24. BOOK/REPORT 
    To Err Is Human: Building a Safer Health System.
    Kohn L, Corrigan J, Donaldson M, eds. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
  25. COMMENTARY
    A patient safety checklist for the cardiac catheterisation laboratory.
    Cahill TJ, Clarke SC, Simpson IA, Stables RH. Heart. 2014 Dec 5; [Epub ahead of print].
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