AHRQ Patient Safety Network

What's New

The latest additions to our collection of annotated links to patient safety literature, news, and other resources.

5/22/2013

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BOOK/REPORT

Book/Report

Second Victim: Error, Guilt, Trauma, and Resilience.

Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.

JOURNAL ARTICLE

Commentary

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

Myers JS, Tess A, Glasheen JJ, et al. Am J Med Qual. 2013 Apr 11; [Epub ahead of print].

The science of human factors: separating fact from fiction.

Russ AL, Fairbanks RJ, Karsh BT, Militello LG, Saleem JJ, Wears RL. BMJ Qual Saf. 2013 Apr 16; [Epub ahead of print].

Review

Duty-hour limits and patient care and resident outcomes: can high-quality studies offer insight into complex relationships?

Philibert I, Nasca T, Brigham T, Shapiro J. Annu Rev Med. 2013;64:467-483.

The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.

Georgiou A, Prgomet M, Paoloni R, et al. Ann Emerg Med. 2013;61:644-653.

The high-reliability pediatric intensive care unit.

Niedner MF, Muething SE, Sutcliffe KM. Pediatr Clin North Am. 2013;60:563-580.

Study

Current approaches to punitive action for medication errors by boards of pharmacy.

Holdsworth M, Wittstrom K, Yeitrakis T. Ann Pharmacother. 2013;47:475-481.

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

Jothiraj H, Howland-Harris J, Evley R, Moppett IK. Br J Anaesth. 2013 Apr 16; [Epub ahead of print].

Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?

Sibbald M, De Bruin ABH, van Merrienboer JJG. Adv Health Sci Educ Theory Pract. 2013 Apr 27; [Epub ahead of print].

Flow disruptions in trauma care handoffs.

Catchpole KR, Gangi A, Blocker RC, et al. J Surg Res. 2013 Mar 13; [Epub ahead of print].

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

Huis A, Schoonhoven L, Grol R, Donders R, Hulscher M, van Achterberg T. Int J Nurs Stud. 2013;50:464-474.

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

Mitchell EL, Lee DY, Arora S, et al. Acad Med. 2013 Apr 24; [Epub ahead of print].

The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses.

Wang CJ, Fetzer SJ, Yang YC, Wang JJ. Geriatr Nurs. 2013;34:138-145.

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

MEETING/CONFERENCE

Illinois Meeting/Conference

6th International Conference: Diagnostic Error in Medicine.

Society to Improve Diagnosis in Medicine. September 22–25, 2013; Northwestern University Feinberg School of Medicine, Chicago, IL.

Washington Meeting/Conference

Mistake Proofing Healthcare Workshop.

Virginia Mason Institute. June 19–20, 2013; Virginia Mason Institute, Seattle, WA.

NEWSPAPER/MAGAZINE ARTICLE

Newspaper/Magazine Article

Leapfrog hospital safety scores 'depressing.'

Clark C. HealthLeaders Media. May 9, 2013.

Misdiagnosis is more common than drug errors or wrong-site surgery.

Boodman SG. Washington Post. May 6, 2013.

SPECIAL OR THEME ISSUE

Special or Theme Issue

Safety in Numbers: Evidence-based Development of a Medicine Management Learning Tool.

Holland K, ed. Nurse Educ Pract. 2013;13:e1-e87.

Also of Note...

Ideas to Innovation: Stimulating Collaborations in the Application of Resilience Engineering to Healthcare. Medstar Healthcare and University-Industry Demonstration Partnership. June 13–14, 2013; Keck Center of the National Academies, Washington, DC.

2013 SEIPS Short Course on Human Factors Engineering and Patient Safety Extended Part I: Human Factors and Sociotechnical Systems Engineering. Center for Quality and Productivity Improvement. July 15–18, 2013; The Lowell Center, University of Wisconsin-Extension, Madison, WI.