U.S. Department of Health & Human Services
Annotated links to patient safety literature, news, and other resources.
The 25 most-viewed-items, updated weekly.
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.
An analysis of electronic health record–related patient safety concerns.
Meeks DW, Smith MW, Taylor L, Sittig DF, Scott JM, Singh H. J Am Med Inform Assoc. 2014 Jun 20; [Epub ahead of print].
Patient Safety and the "Just Culture": A Primer for Health Care Executives.
Marx D. New York, NY: Columbia University; 2001.
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2013.
Impact of interventions designed to reduce medication administration errors in hospitals: a systematic review.
Keers RN, Williams SD, Cooke J, Walsh T, Ashcroft DM. Drug Saf. 2014;37:317-332.
More than 750 hospitals face Medicare crackdown on patient injuries.
Rau J. Kaiser Health News. June 22, 2014.
Walkrounds in practice: corrupting or enhancing a quality improvement intervention? A qualitative study.
Martin G, Ozieranski P, Willars J, et al. Jt Comm J Qual Patient Saf. 2014;40:303-310.
A comprehensive obstetric patient safety program reduces liability claims and payments.
Pettker CM, Thung SF, Lipkind HS, et al. Am J Obstet Gynecol. 2014 Jun 9; [Epub ahead of print].
Identification and interference of intraoperative distractions and interruptions in operating rooms.
Antoniadis S, Passauer-Baierl S, Baschnegger H, Weigl M. J Surg Res. 2014;188:21-29.
10 years in, why time out still matters.
Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
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].
Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.
Nanji KC, Rothschild JM, Boehne JJ, Keohane CA, Ash JS, Poon EG. J Am Med Inform Assoc. 2014;21:481-486.
How mistakes can save lives: one man's mission to revolutionise the NHS.
Leslie I. New Statesman. June 4, 2014.
Restoring trust in VA health care.
Kizer KW, Jha AK. N Engl J Med. 2014 Jun 4; [Epub ahead of print].
Stress on the ward: evidence of safety tipping points in hospitals.
Kuntz L, Mennicken R, Scholtes S. Manage Sci. 2014 May 14; [Epub ahead of print].
A cycle of redemption in a medical error disclosure and apology program.
Carmack HJ. Qual Health Res. 2014;24:860-869.
Medical Office Survey on Patient Safety Culture: 2014 User Comparative Database Report.
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF.
Quiet please! Drug round tabards: are they effective and accepted? A mixed method study.
Verweij L, Smeulers M, Maaskant JM, Vermeulen H. J Nurs Scholarsh. 2014 Jun 13; [Epub ahead of print].
The limits of checklists: handoff and narrative thinking.
Hilligoss B, Moffatt-Bruce SD. BMJ Qual Saf. 2014;23:528-533.
Finding and Preventing Patient Safety Incidents.
Golden, CO: HealthGrades, Inc.; June 9, 2014.
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.
Patient Safety Culture Surveys.
Rockville, MD: Agency for Healthcare Research and Quality; April 2014.
Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system.
Woods AD, Mulherin DP, Flynn AJ, Stevenson JG, Zimmerman CR, Chaffee BW. J Am Med Inform Assoc. 2014;21:569-573.
Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study.
Borghans I, Hekkert KD, den Ouden L, et al. BMJ Open. 2014;4:e004773.
Multifaceted interventions improve adherence to the surgical checklist.
Putnam LR, Levy SM, Sajid M, et al. Surgery. 2014;156:336-344.
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