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COMMENTARY
Creating high reliability in health care organizations.
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
NEWSPAPER/MAGAZINE ARTICLE
Practitioners agree on medication reconciliation value, but frustration and difficulties abound.
ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.
STUDYclassic
Patient safety concerns arising from test results that return after hospital discharge.
Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.
STUDY
Medical errors arising from outsourcing laboratory and radiology services.
Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.
STUDY
Medical emergency team calls in the radiology department: patient characteristics and outcomes.
Ott LK, Pinsky MR, Hoffman LA, et al. BMJ Qual Saf. 2012 Mar 2; [Epup ahead of print].
COMMENTARY
Medication bar coding: to scan or not to scan?
Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.
STUDY
"I wish I had seen this test result earlier!": dissatisfaction with test result management systems in primary care.
Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. Arch Intern Med. 2004;164:2223-2228.
ORGANIZATIONAL POLICY/GUIDELINES
2008 Recommendations for Pre-Anesthesia Checkout Procedures. 
ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008. 
STUDY
Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.
Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.
BOOK/REPORT
Recommendations for Safe Use of Insulin in Hospitals.
Bethesda, MD: American Society of Health-System Pharmacists; 2006.
STUDYclassic
Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.
Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.
COMMENTARY
Best-practice protocols: Preventing adverse drug events.
Weir VL. Nurs Manage. 2005;36:24-30.
ORGANIZATIONAL POLICY/GUIDELINES
Health care worker fatigue and patient safety.
Sentinel Event Alert. December 14, 2011;(48):1-4.
STUDY
Patient misidentification in the neonatal intensive care unit: quantification of risk.
Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.
STUDY
"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.
Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.
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