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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. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  3. MULTI-USE WEBSITE
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2013.
  4. REVIEW
    Identifying high-risk medication: a systematic literature review.
    Saedder EA, Brock B, Nielsen LP, Bonnerup DK, Lisby M. Euro J Clin Pharmacol. 2014;70:637-645.
  5. CONGRESSIONAL TESTIMONY
    More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
    Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014). (Testimony of John James, PhD; Ashish Jha, MD, MPH; Tejal Gandhi, MD, MPH; Peter Pronovost, MD, PhD; Joanne Disch, PhD, RN; Lisa McGiffert.)
  6. 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].
  7. BOOK/REPORT
    Hospital Experiences Using Electronic Health Records to Support Medication Reconciliation.
    Grossman JM, Gourevitch R, Cross D. Washington, DC: National Institute for Health Care Reform; July 2014. NIHCR Research Brief No. 17.
  8. COMMENTARY
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  9. STUDY
    Electronic health record–related safety concerns: a cross-sectional survey.
    Menon S, Singh H, Meyer AN, Belmont E, Sittig DF. J Healthc Risk Manag. 2014;34:14-26.
  10. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  11. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  12. STUDY
    Morning handover of on-call issues: opportunities for improvement.
    Devlin MK, Kozij NK, Kiss A, Richardson L, Wong BM. JAMA Intern Med. 2014 Jul 21; [Epub ahead of print].
  13. COMMENTARY
    Deafening silence? Time to reconsider whether organisations are silent or deaf when things go wrong.
    Jones A, Kelly D. BMJ Qual Saf. 2014;23:709-713.
  14. NEWSPAPER/MAGAZINE ARTICLE
    Feds stop public disclosure of many serious hospital errors.
    O'Donnell J. USA Today. August 6, 2014.
  15. STUDY
    Decreasing handoff-related care failures in children's hospitals.
    Bigham MT, Logsdon TR, Manicone PE, et al. Pediatrics. 2014;134:e572-e579.
  16. STUDY
    Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives.
    Richter JP, McAlearney AS, Pennell ML. Am J Med Qual. 2014 Jul 28; [Epub ahead of print].
  17. REVIEW
    Interventions to reduce pediatric medication errors: a systematic review.
    Rinke ML, Bundy DG, Velasquez CA, et al. Pediatrics. 2014;134:338-360.
  18. COMMENTARY
    Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?
    Myers JS, Nash DB. Acad Med. 2014 Jul 22; [Epub ahead of print].
  19. 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.
  20. BOOK/REPORT
    Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
    Hughes RG, ed. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.  
  21. COMMENTARY
    Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence.
    Dankoski ME, Bickel J, Gusic ME. Acad Med. 2014 Jul 22; [Epub ahead of print].
  22. STUDY
    The WHO surgical safety checklist: survey of patients' views.
    Russ SJ, Rout S, Caris J, et al. BMJ Qual Saf. 2014 Jul 18; [Epub ahead of print].
  23. STUDY
    Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.
    Gibson A, Tevis S, Kennedy G. Am J Surg. 2014;207:832-839.
  24. STUDY
    The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend.
    Goldstein SD, Papandria DJ, Aboagye J, et al. J Pediatr Surg. 2014;49:1087-1091.
  25. BOOK/REPORT 
    The Definition of Quality and Approaches to Its Assessment. Vol 1. Explorations in Quality Assessment and Monitoring.
    Donabedian A. Ann Arbor, MI: Health Administration Press; 1980.
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