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Journal Article

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

Brown CL, Mulcaster HL, Triffitt KL, et al. J Am Med Inform Assoc. 2016 Aug 30; [Epub ahead of print].

Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students.

Kow AWC, Ang BLS, Chong CS, Tan WB, Menon KR. World J Surg. 2016 Jul 14; [Epub ahead of print].

Association of inpatient hospital experience with patient safety indicators: a cross-sectional, Canadian study.

Kemp KA, Santana MJ, Southern DA, McCormack B, Quan H. BMJ Open. 2016;6:e011242.

Collaboration with regulators to support quality and accountability following medical errors: the communication and resolution program certification pilot.

Gallagher TH, Farrell ML, Karson H, et al. Health Serv Res. 2016 Sep 7; [Epub ahead of print].

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

Cochran GL, Barrett RS, Horn SD. Am J Health Syst Pharm. 2016;73:1167-1173.

Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention.

Novosad SA, Sapiano MR, Grigg C, et al. MMWR Morb Mortal Wkly Rep. 2016;65:864-869.

Health care worker fatigue.

Gardner LA, Dubeck D. Am J Nurs. 2016;116:58-62.

A piece of my mind. Snakes on a dock.

Detsky AS. JAMA. 2016;316:1043-1044.

The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff.

MacDougall-Davis SR, Kettley L, Cook TM. Anaesthesia. 2016;71:764-772.

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

Soban LM, Kim L, Yuan AH, Miltner RS. J Nurs Manag. 2016 Aug 4; [Epub ahead of print].

Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.

Van Gerven E, Bruyneel L, Panella M, Euwema M, Sermeus W, Vanhaecht K. BMJ Open. 2016;6:e011403.

Newspaper/Magazine Article

Raising an alarm, doctors fight to yank hospital ICUs into the modern era.

McFarling UL. STAT. September 7, 2016.

'Superbug' scourge spreads as U.S. fails to track rising human toll.

McNeill R, Nelson DJ, Abutaleb Y. Reuters Investigation. September 7, 2016.

Web Resource

Shift to Safety.

Canadian Patient Safety Institute.


NPSF Spotlight Series: Implementing RCA2: Lessons From the Trenches.

National Patient Safety Foundation. October 4, 11, 18, and 25, 2016; 1:00–2:00 PM (Eastern).

Also of Note

AHRQ Research Summit on Improving Diagnosis in Health Care.

Agency for Healthcare Research and Quality. September 28, 2016. Agency for Healthcare Research and Quality, Rockville, MD.

Leveraging the Principles of High Reliability to Advance Patient and Family Engagement in Safety.

Institute for Patient- and Family-Centered Care. October 6, 2016; 1:00–2:00 PM (Eastern).

Advancing Patient Safety Implementation Through Safe Medication Use Research (R18).

Rockville, MD: Agency for Healthcare Research and Quality. PA-14-002.

WebM&M Cases

A Pill Organizing Plight

  • Spotlight Case

Commentary by Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

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Complaints as Safety Surveillance

Commentary by Jennifer Morris and Marie Bismark, MD

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Wrong-Time Error With High-Alert Medication

Commentary by Annie Yang, PharmD, and Lewis Nelson, MD

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

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Perspectives on Safety

Telemedicine and Patient Safety


In Conversation With… Reed V. Tuckson, MD

Dr. Tuckson is President of the American Telemedicine Association. We spoke with him about telemedicine and patient safety.


Telemedicine and Patient Safety

Stephen Agboola, MD, MPH, and Joseph Kvedar, MD

This piece explores benefits and safety concerns associated with the increased adoption of telemedicine services.

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