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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. 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.
  4. BOOK/REPORT 
    Patient Safety and the "Just Culture": A Primer for Health Care Executives.
    Marx D. New York, NY: Columbia University; 2001.
  5. STUDY
    Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.
    Armor BL, Wight AJ, Carter SM. J Pharm Pract. 2014 Oct 13; [Epub ahead of print].
  6. REVIEW
    Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.
    Dunbar NM, Szczepiorkowski ZM. Curr Opin Hematol. 2014;21:515-520.
  7. NEWSPAPER/MAGAZINE ARTICLE
    The human factor.
    Langewiesche W. Vanity Fair. October 2014.
  8. COMMENTARY
    Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records.
    Upadhyay DK, Sittig DF, Singh H. Diagnosis. 2014 Oct 23; [Epub ahead of print].
  9. STUDY
    Out-of-hospital medication errors among young children in the United States, 2002–2012.
    Smith MD, Spiller HA, Casavant MJ, Chounthirath T, Brophy TJ, Xiang H. Pediatrics. 2014;134:867-876.
  10. 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].
  11. COMMENTARY
    A cycle of redemption in a medical error disclosure and apology program.
    Carmack HJ. Qual Health Res. 2014;24:860-869.
  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. COMMENTARY
    Restoring trust in VA health care.
    Kizer KW, Jha AK. N Engl J Med. 2014;371:295-297.
  14. STUDY
    Evaluating inpatient mortality: a new electronic review process that gathers information from front-line providers.
    Provenzano A, Rohan S, Trevejo E, Burdick E, Lipsitz S, Kachalia A. BMJ Qual Saf. 2014 Oct 20; [Epub ahead of print].
  15. SPECIAL OR THEME ISSUE
    Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program.
    Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.
  16. STUDY
    On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile.
    Weaver SJ, Weeks K, Pham JC, Pronovost PJ. Am J Infect Control. 2014;42(suppl 10):S203-S208.
  17. SPECIAL OR THEME ISSUE
    Health IT and Clinical Decision Support Systems.
    Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
  18. STUDY
    Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.
    Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.
  19. 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].
  20. STUDY
    Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.
    Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.
  21. STUDY
    Incidents resulting from staff leaving normal duties to attend medical emergency team calls.
    Cheung W, Sahai V, Mann-Farrar J, et al; Concord Medical Emergency Team (MET) Incidents Study Investigators. Med J Aust. 2014;201:528-531.
  22. STUDY
    Validating administrative data for the detection of adverse events in older hospitalized patients.
    Ackroyd-Stolarz S, Bowles SK, Giffin L. Drug Healthc Patient Saf. 2014;6:101-108.
  23. 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.
  24. STUDY
    Exposing physicians to reduced residency work hours did not adversely affect patient outcomes after residency.
    Jena AB, Schoemaker L, Bhattacharya J. Health Aff (Millwood). 2014;33:1832-1840.
  25. SPECIAL OR THEME ISSUE
    From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.
    Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.
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