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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.
    National Patient Safety Goals.
    Oakbrook Terrace, IL: The Joint Commission; 2013.
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
    Did hospital engagement networks actually improve care?
    Pronovost P, Jha AK. N Engl J Med. 2014;371:691-693.
    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].
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
    10 years in, why time out still matters.
    Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
    The role of hospital managers in quality and patient safety: a systematic review.
    Parand A, Dopson S, Renz A, Vincent C. BMJ Open. 2014;4:e005055.
  10. STUDY
    Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
    Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].
    The systems approach to medicine: controversy and misconceptions.
    Dekker SWA, Leveson NG. BMJ Qual Saf. 2014 Aug 7; [Epub ahead of print].
  12. STUDY
    Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM.
    Boyd AD, Yang YM, Li J, et al. J Am Med Inform Assoc. 2014 Sep 3; [Epub ahead of print].
  13. STUDY
    Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training.
    Jha V, Buckley H, Gabe R, et al. BMJ Qual Saf. 2014 Aug 18; [Epub ahead of print].
  14. STUDY
    Health information technology and hospital patient safety: a conceptual model to guide research.
    Paez K, Roper RA, Andrews RM. Jt Comm J Qual Patient Saf. 2013;39:415-425.
  15. STUDY
    The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.
    Keenan JE, Speicher PJ, Thacker JKM, Walter M, Kuchibhatla M, Mantyh CR. JAMA Surg. 2014 Aug 27; [Epub ahead of print].
  16. STUDY
    Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
    McKaig D, Collins C, Elsaid KA. Jt Comm J Qual Patient Saf. 2014;40;9:398-407.
    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.  
  18. STUDY
    Catastrophic medical malpractice payouts in the United States.
    Bixenstine PJ, Shore AD, Mehtsun WT, Ibrahim AM, Freischlag JA, Makary MA. J Healthc Qual. 2014;36:43-53.
  19. STUDY
    Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
    Stawicki SP, Cook CH, Anderson HL III, et al; OPUS 12 Foundation Multicenter Trials Group. Am J Surg. 2014;208:65-72.
  20. STUDY
    The relationship between hospital systems load and patient harm.
    Pedroja AT, Blegen MA, Abravanel R, Stromberg AJ, Spurlock B. J Patient Saf. 2014;10:168-175.
    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.
    Feds reverse course, will release hospital mistake data.
    O'Donnell J. USA Today. September 7, 2014.
  23. STUDY
    Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.
    Micek ST, Heard KM, Gowan M, Kollef MH. Crit Care Med. 2014;42:1832-1838.
    Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.
    Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
  25. STUDY
    Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
    Galanter WL, Bryson ML, Falck S, et al. PLoS One. 2014;9:e101977.
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