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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
    America's Hospitals: Improving Quality and Safety: The Joint Commission's Annual Report 2014.
    Oakbrook Terrace, IL: The Joint Commission; November 2014.
  4. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  5. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  6. STUDY
    The impact of time at work and time off from work on rule compliance: the case of hand hygiene in health care.
    Dai H, Milkman KL, Hofmann DA, Staats BR. J Appl Psychol. 2014 Nov 3; [Epub ahead of print].
  7. BOOK/REPORT
    AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report.
    Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
  8. 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].
  9. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  10. COMMENTARY
    Patient safety goals for the proposed Federal Health Information Technology Safety Center.
    Sittig DF, Classen DC, Singh H. J Am Med Inform Assoc. 2014 Oct 20; [Epub ahead of print].
  11. STUDY
    Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study.
    Srigley JA, Furness CD, Baker GR, Gardam M. BMJ Qual Saf. 2014;23:974-980.
  12. COMMENTARY
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  13. REVIEW
    Conflict of interest, Dr Charles Denham and the Journal of Patient Safety.
    Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
  14. STUDY
    How context affects electronic health record–based test result follow-up: a mixed-methods evaluation.
    Menon S, Smith MW, Sittig DF, et al. BMJ Open. 2014;4:e005985.
  15. BOOK/REPORT
    Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
    Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
  16. STUDY
    Improving healthcare systems' disclosures of large-scale adverse events: a Department of Veterans Affairs leadership, policymaker, research and stakeholder partnership.
    Elwy AR, Bokhour BG, Maguire EM, et al. J Gen Intern Med. 2014 Oct 30; [Epub ahead of print].
  17. COMMENTARY
    The medical liability climate and prospects for reform.
    Mello MM, Studdert DM, Kachalia A. JAMA. 2014;312:2146-2155.
  18. STUDY
    Medical harm: patient perceptions and follow-up actions.
    Lyu HG, Cooper MA, Mayer-Blackwell B, et al. J Patient Saf. 2014 Nov 13; [Epub ahead of print].
  19. 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.
  20. 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.
  21. STUDY
    A team-based approach to reducing cardiac monitor alarms.
    Dandoy CE, Davies SM, Flesch L, et al. Pediatrics. 2014;134:e1686-e1694.
  22. BOOK/REPORT
    Reporting and Learning Systems for Medication Errors: The Role of Pharmacovigilance Centres.
    Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October 2014. ISBN: 9789241507943.
  23. STUDY
    Driven to distraction: a prospective controlled study of a simulated ward round experience to improve patient safety teaching for medical students.
    Thomas I, Nicol L, Regan L, et al. BMJ Qual Saf. 2014 Nov 24; [Epub ahead of print].
  24. COMMENTARY
    Learning from failure: the need for independent safety investigation in healthcare.
    Macrae C, Vincent C. J R Soc Med. 2014;107:439-443.
  25. 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.
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