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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. MULTI-USE WEBSITE
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2014.
  3. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  4. REVIEW
    Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.
    Dunbar NM, Szczepiorkowski ZM. Curr Opin Hematol. 2014;21:515-520.
  5. STUDY
    Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.
    Armor BL, Wight AJ, Carter SM. J Pharm Pract. 2014 Oct 13; [Epub ahead of print].
  6. STUDY 
    Changes in medical errors after implementation of a handoff program.
    Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group. N Engl J Med. 2014;371:1803-1812.
  7. NEWSPAPER/MAGAZINE ARTICLE
    The human factor.
    Langewiesche W. Vanity Fair. October 2014.
  8. COMMENTARY
    Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.
    Upadhyay DK, Sittig DF, Singh H. Diagnosis. 2014 Oct 23; [Epub ahead of print].
  9. STUDY
    Out-of-hospital medication errors among young children in the United States, 2002–2012.
    Smith MD, Spiller HA, Casavant MJ, Chounthirath T, Brophy TJ, Xiang H. Pediatrics. 2014;134:867-876.
  10. STUDY
    Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?
    Balint BJ, Steenburg SD, Lin H, Shen C, Steele JL, Gunderman RB. Acad Radiol. 2014 Sep 30; [Epub ahead of print].
  11. REVIEW
    Benefits and risks of using smart pumps to reduce medication error rates: a systematic review.
    Ohashi K, Dalleur O, Dykes PC, Bates DW. Drug Saf. 2014 Oct 8; [Epub ahead of print].
  12. 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].
  13. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  14. SPECIAL OR THEME ISSUE
    Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program.
    Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.
  15. STUDY
    Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
    Provenzano A, Rohan S, Trevejo E, Burdick E, Lipsitz S, Kachalia A. BMJ Qual Saf. 2014 Oct 20; [Epub ahead of print].
  16. COMMENTARY
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  17. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  18. STUDY
    Time of day and the decision to prescribe antibiotics.
    Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014 Oct 6; [Epub ahead of print].
  19. STUDY
    Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
    Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
  20. STUDY
    Validating administrative data for the detection of adverse events in older hospitalized patients.
    Ackroyd-Stolarz S, Bowles SK, Giffin L. Drug Healthc Patient Saf. 2014;6:101-108.
  21. 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.
  22. STUDY
    Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency.
    Jena AB, Schoemaker L, Bhattacharya J. Health Aff (Millwood). 2014;33:1832-1840.
  23. STUDY
    Systematic biases in group decision-making: implications for patient safety.
    Mannion R, Thompson C. Int J Qual Health Care. 2014 Oct 15; [Epub ahead of print].
  24. SPECIAL OR THEME ISSUE
    From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.
    Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
  25. COMMENTARY
    Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care.
    Gray D, Johnson KD, Watts B. Jt Comm J Qual Patient Saf. 2014;40:514-521.
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