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Journal Article

Relationship between operating room teamwork, contextual factors, and safety checklist performance.

Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016 Jul 25; [Epub ahead of print].

Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.

Segall N, Bonifacio AS, Barbeito A, et al. Jt Comm J Qual Patient Saf. 2016;42:400-414.

Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.

Nguyen OK, Makam AN, Clark C, et al. J Gen Intern Med. 2016 Aug 8; [Epub ahead of print].

Patient safety climate strength: a concept that requires more attention.

Ginsburg L, Gilin Oore D. BMJ Qual Saf. 2016;25:680-687.

Context-sensitive decision support (infobuttons) in electronic health records: a systematic review.

Cook DA, Teixeira MT, Heale BSE, Cimino JJ, Del Fiol G. J Am Med Inform Assoc. 2016 Aug 7; [Epub ahead of print].

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

Applying the high reliability health care maturity model to assess hospital performance: a VA case study.

Sullivan JL, Rivard PE, Shin MH, Rosen AK. Jt Comm J Qual Patient Saf. 2016;42:389-411.

The multidisciplinary approach to GI cancer results in change of diagnosis and management of patients. Multidisciplinary care impacts diagnosis and management of patients.

Meguid C, Schulick RD, Schefter TE, et al. Ann Surg Oncol. 2016 Jun 24; [Epub ahead of print].

Burnout in the nursing home health care aide: a systematic review.

Cooper SL, Carleton HL, Chamberlain SA, Cummings GG, Bambrick W, Estabrooks CA. Burnout Res. 2016;3:76-87.

Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor.

Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-366.

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2016 Aug 4; [Epub ahead of print].

The problem with medication reconciliation.

Pevnick JM, Shane R, Schnipper JL. BMJ Qual Saf. 2016;25:726-730.

Book/Report

Learning From Mistakes.

London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.

Meeting/Conference

Just Culture: Application of an Accountability Model With Medication Safety Events.

Institute for Safe Medication Practices. September 29, 2016; 1:30–3:00 PM (Eastern).

Also of Note

Patient Safety and Healthcare Quality Improvement 2016.

Harvard Medical School. September 26–27, 2016; Sheraton Boston Hotel, Boston, MA.

Patient Safety Curriculum.

National Patient Safety Foundation.

WebM&M Cases

Cognitive Overload in the ICU

  • Spotlight Case
  • CME/CEU

Commentary by Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

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Getting the (Right) Doctor, Right Away

Commentary by Kiran Gupta, MD, MPH, and Raman Khanna, MD

A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.

Falling Between the Cracks in the Software

Commentary by Julia Adler-Milstein, PhD

Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.

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Perspectives on Safety

Patient Safety in Dentistry

Interview

In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD

Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.

Perspective

Safety In Dentistry

Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD

This piece examines patient safety issues unique to dental care along with strategies to reduce risks.

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Did You Know?

Most e-prescription errors were detected during inputting phase.

Source

Popular Content

Study

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Arriaga AF, Gawande AA, Raemer DB, et al; Harvard Surgical Safety Collaborative. Ann Surg. 2014;259:403-410.

Review

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

Study

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

Roland D, Oliver A, Edwards ED, Mason BW, Powell CVE. Arch Dis Child. 2014;99:26-29.

Multi-use Website

Preventing Falls With Injury.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; August 2015.

Commentary

Continuous improvement as an ideal in health care.

Berwick DM. N Engl J Med. 1989;320:53-56.