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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. STUDY
    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].
  3. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  4. MULTI-USE WEBSITE
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2013.
  5. STUDY
    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.
  6. STUDY
    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.
  7. NEWSPAPER/MAGAZINE ARTICLE
    More than 750 hospitals face Medicare crackdown on patient injuries.
    Rau J. Kaiser Health News. June 22, 2014.
  8. STUDY
    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.
  9. STUDY
    Multifaceted interventions improve adherence to the surgical checklist.
    Putnam LR, Levy SM, Sajid M, et al. Surgery. 2014;156:336-344.
  10. REVIEW
    Clinical questions raised by clinicians at the point of care: a systematic review.
    Del Fiol G, Workman TE, Gorman PN. JAMA Intern Med. 2014;174:710-718.
  11. STUDY
    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].
  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
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
  14. STUDY
    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].
  15. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  16. STUDY
    Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy.
    Parsons JK, Messer K, Palazzi K, Stroup S, Chang D. JAMA Surg. 2014 Jul 2; [Epub ahead of print].
  17. BOOK/REPORT
    Promoting Patient Safety Through Effective Health Information Technology Risk Management.
    Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC: Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
  18. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  19. BOOK/REPORT
    Finding and Preventing Patient Safety Incidents.
    Golden, CO: HealthGrades, Inc.; June 9, 2014.
  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
    Wrong-side thoracentesis: lessons learned from root cause analysis.
    Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014 Jun 11; [Epub ahead of print].
  22. REVIEW
    Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients.
    Smeulers M, Lucas C, Vermeulen H. Cochrane Database Syst Rev. 2014;6:CD009979.
  23. STUDY
    Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.
    Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014 Jun 6; [Epub ahead of print].
  24. MEASUREMENT TOOL/INDICATOR 
    Patient Safety Indicators Download.
    AHRQ Quality Indicators. Rockville, MD: Agency for Healthcare Research and Quality; March 2012.
  25. STUDY
    Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.
    Johnston M, Arora S, King D, Stroman L, Darzi A. Surgery. 2014;155:989-994.
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