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Journal Article

Performance of a trigger tool for identifying adverse events in oncology.

Lipitz-Snyderman A, Classen D, Pfister D, et al. J Oncol Pract. 2017;13:e223-e230.

Pictograms, units and dosing tools, and parent medication errors: a randomized study.

Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2017;140:e20163237.

Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project.

Schiff GD, Reyes Nieva H, Griswold P, et al. Med Care. 2017 Jun 23; [Epub ahead of print].

The evolving story of overlapping surgery.

Mello MM, Livingston EH. JAMA. 2017 Jun 28; [Epub ahead of print].

Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program.

Kane RL, Huckfeldt P, Tappen R, et al. JAMA Intern Med. 2017 Jul 3; [Epub ahead of print].

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

De Oliveira GS Jr, Castro-Alves LJ, Kendall MC, McCarthy R. J Patient Saf. 2017 Jun 30; [Epub ahead of print].

The opioid epidemic: what can surgeons do about it?

Saluja S, Selzer D, Meara JG, Heneghan K, Daly JM. Bull Am Coll Surg. 2017;102.

Do hospitals support second victims? Collective insights from patient safety leaders in Maryland.

Edrees HH, Morlock L, Wu AW. Jt Comm J Qual Patient Saf. 2017 Jun 29; [Epub ahead of print].

Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores.

Stafos A, Stark S, Barbay K, et al. Am J Nurs. 2017;117:26-31.

The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference.

Hoffman RL, Morris JB, Kelz RR. JAMA Surg. 2017 July 17; [Epub ahead of print].

Book/Report

Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.

Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.

Newspaper/Magazine Article

Errors originating in hospital and health-system outpatient pharmacies.

Straka M, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. 2017;14:55-63.

Half the time, nursing homes scrutinized on safety by Medicare are still treacherous.

Rau J. Kaiser Health News. July 6, 2017.

Press Release/Announcement

ISMP Survey on Texting Medical Orders.

Institute for Safe Medication Practices.

Also of Note

Speak Up for Patient Safety: Communicating Before, During and After an Adverse Event.

Oregon Patient Safety Commission. August 11, 2017; OMEF Event Center, Portland, OR.

Preventing Overdiagnosis.

Quebec Medical Association. August 17–19, 2017; Québec City Convention Centre, Quebec City, Canada.

WebM&M Cases

Pseudo-obstruction But a Real Perforation

  • Spotlight Case
  • CME/CEU

Commentary by Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

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Delayed Recognition of a Positive Blood Culture

Commentary by Sarah Doernberg, MD, MAS

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

The Hidden Harms of Hand Sanitizer

Commentary by Stephen Stewart, MBChB, PhD

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

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Perspectives on Safety

Legal Issues and Patient Safety

Interview

In Conversation With… Michelle Mello, MPhil, JD, PhD

Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.

Perspective

Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know?

David Studdert, LLB, ScD

This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

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Did You Know?

Patient impacts of medication errors associated with CPOE.

Source

Popular Content

Study

Computerised provider order entry and residency education in an academic medical centre.

Wong B, Kuper A, Robinson N, et al. Med Educ. 2012;46:795-806.

Audiovisual

It's time to say sorry.

Coombes R. BMJ Podcast. June 1, 2012.

Review

Evaluation and certification of computerized physician order entry systems.

Classen D, Avery AJ, Bates DW. J Am Med Inform Assoc. 2007;14:48-55.

Commentary

Eliminating adverse drug events at Ascension Health.

Butler K, Mollo P, Gale JL, Rapp DA. Jt Comm J Qual Patient Saf. 2007;33:527-536.

Newspaper/Magazine Article

Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2.

ISMP Medication Safety Alert! Acute Care Edition. January 28, 2016;21:1-4. February 11, 2016;21:1-5.