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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
    Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human.'
    Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. BMJ Qual Saf. 2015 Jul 27; [Epub ahead of print].
  2. STUDY
    Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
    Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R. Health Aff (Millwood). 2015;34:1304-1311.
  3. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  4. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  5. REVIEW
    Discussing harm-causing errors with patients: an ethics primer for plastic surgeons.
    Vercler CJ, Buchman SR, Chung KC. Ann Plast Surg. 2015;74:140-144.
  6. COMMENTARY
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  7. STUDY
    Preventability of hospital-acquired venous thromboembolism.
    Haut ER, Lau BD, Kraus PS, et al. JAMA Surg. 2015 Jul 29; [Epub ahead of print].
  8. STUDY
    Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis.
    Hogan H, Zipfel R, Neuburger J, Hutchings A, Darzi A, Black N. BMJ. 2015;351:h3239.
  9. MULTI-USE WEBSITE
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2015.
  10. STUDY
    Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.
    Rajaram R, Chung JW, Kinnier CV, et al. JAMA. 2015;314:375-383.
  11. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  12. STUDY
    Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society.
    Nuckols TK, Asch SM, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:341-350.
  13. STUDY
    The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation.
    Sanchez Cuervo M, Rojo Sanchis A, Pueyo Lopez C, Gomez de Salazar Lopez de Silanes E, Gramage Caro T, Bermejo Vicedo T. J Clin Pharm Ther. 2015 Jul 14; [Epub ahead of print].
  14. REVIEW 
    Interventions employed to improve intrahospital handover: a systematic review.
    Robertson ER, Morgan L, Bird S, Catchpole K, McCulloch P. BMJ Qual Saf. 2014;23:600-607.
  15. REVIEW
    Look alike/sound alike drugs: a literature review on causes and solutions.
    Ciociano N, Bagnasco L. Int J Clin Pharm. 2014;36:233-242.
  16. STUDY
    Attitudes and practices related to clinical alarms.
    Funk M, Clark JT, Bauld TJ, Ott JC, Coss P. Am J Crit Care. 2014;23:e9-e18.
  17. STUDY
    Adverse drug event–related emergency department visits associated with complex chronic conditions.
    Feinstein JA, Feudtner C, Kempe A. Pediatrics. 2014;133:e1575-e1585.
  18. MARYLAND MEETING/CONFERENCE
    CUSP Implementation Workshop.
    Armstrong Institute for Patient Safety and Quality. October 6, 2015; Constellation Energy Building Conference Center, Baltimore, MD.
  19. STUDY
    Ambulance diversion associated with reduced access to cardiac technology and increased one-year mortality.
    Shen YC, Hsia RY. Health Aff (Millwood). 2015;34:1273-1280.
  20. STUDY
    ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2014.
    Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2015;72:1119-1137.
  21. STUDY
    "It is the left eye, right?"
    Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
  22. BOOK/REPORT
    Hospital Reporting Program.
    Portland, OR: Oregon Patient Safety Commission.
  23. STUDY 
    Investigating the long-term consequences of adverse medical events among older adults.
    Carter MW, Zhu M, Xiang J, Porell FW. Inj Prev. 2014;20:408-415.
  24. STUDY
    Problem list completeness in electronic health records: a multi-site study and assessment of success factors.
    Wright A, McCoy AB, Hickman TT, et al. Int J Med Inform. 2015 Jul 17; [Epub ahead of print].
  25. STUDY
    Hospital safety scores: do grades really matter?
    Gonzalez AA, Ghaferi AA. JAMA Surg. 2014;149:413-414.
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