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Journal Article

Prognosis of undiagnosed chest pain: linked electronic health record cohort study.

Jordan KP, Timmis A, Croft P, et al. BMJ. 2017;357:j1194.

The relationship between professional burnout and quality and safety in healthcare: a meta-analysis.

Salyers MP, Bonfils KA, Luther L, et al. J Gen Intern Med. 2017;32:475-482.

Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014.

Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. JAMA Intern Med. 2017 Mar 27; [Epub ahead of print].

The effects of bar-coding technology on medication errors: a systematic literature review.

Hutton K, Ding Q, Wellman G. J Patient Saf. 2017 Feb 24; [Epub ahead of print].

Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment.

Zohar D, Werber YT, Marom R, Curlau B, Blondheim O. BMJ Qual Saf. 2017 Jan 12; [Epub ahead of print].

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites.

Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Acad Med. 2017 Mar 28; [Epub ahead of print].

Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams.

Smith PL, McSweeney J. Jt Comm J Qual Patient Saf. 2017 Mar 21; [Epub ahead of print].

Radiology research in quality and safety: current trends and future needs.

Zygmont ME, Itri JN, Rosenkrantz AB, et al. Acad Radiol. 2017;24:263-272.

All consumer medication information is not created equal: implications for medication safety.

Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.


Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study.

Mayor S, Baines E, Vincent C, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2017.

Newspaper/Magazine Article

The opioid crisis: can improving diagnosis help solve the problem?

Carr S. ImproveDx. April 2017;4:1-4.

Why are medical errors still a leading cause of death?

Headley M. Patient Saf Qual Healthc. April 5, 2017.


Leadership, Louder Than Words: C-Suite Ambassadors of Patient Safety.

Center for Patient Safety. May 16, 2017; 1:00–2:00 PM (Eastern).

Also of Note

2017 Northwest Patient Safety Conference.

Washington Patient Safety Coalition. May 11, 2017; Seattle Airport Marriott, Seatac, WA.

Hospital Safety Grade.

Leapfrog Group.

WebM&M Cases

Engaging Seriously Ill Older Patients in Advance Care Planning

  • Spotlight Case

Commentary by Daren K. Heyland, MD, MSc

When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.

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Patient Allergies and Electronic Health Records

Commentary by Matthew J. Doyle, MBBS

Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

Commentary by Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

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Perspectives on Safety

New Thinking About High Reliability


In Conversation With… Mark Chassin, MD, MPP, MPH

Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.


In Conversation With… Kathleen Sutcliffe, MSN, PhD

Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.

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Annual Perspectives

Annual Perspective

Measuring and Responding to Deaths From Medical Errors

Sumant Ranji, MD

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Annual Perspective

Patient Safety and Opioid Medications

Urmimala Sarkar, MD, and Kaveh Shojania, MD

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.

Annual Perspective

Rethinking Root Cause Analysis

Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD

Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.

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Did You Know?

System-related factors that contribute to diagnostic errors.


Popular Content


Medication reconciliation at hospital discharge: evaluating discrepancies.

Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.


Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process.

Bonnabry P, Cingria L, Ackermann M, Sadeghipour F, Bigler L, Mach N. Int J Qual Health Care. 2006;18:9-16.

WebM&M Cases

Picking Up the Cause of the Stroke

Commentary by Vineet Chopra, MD, MSc

Newspaper/Magazine Article

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.

Newspaper/Magazine Article

Heed this warning! Don't miss important computer alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2.