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Journal Article

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.

Cresswell KM, Mozaffar H, Lee L, Williams R, Sheikh A. BMJ Qual Saf. 2016 Apr 29; [Epub ahead of print].

A systematic review of patient safety measures in adult primary care.

Hatoun J, Chan JA, Yaksic E, et al. Am J Med Qual. 2016 Apr 26; [Epub ahead of print].

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.

Winters BD, Bharmal A, Wilson RF, et al. Med Care. 2016 Apr 25; [Epub ahead of print].

Despite federal legislation, shortages of drugs used in acute care settings remain persistent and prolonged.

Chen SI, Fox ER, Hall MK, et al. Health Aff (Millwood). 2016;35:798-804.

Information transfer in multidisciplinary operating room teams: a simulation-based observational study.

Cumin D, Skilton C, Weller J. BMJ Qual Saf. 2016 Mar 16; [Epub ahead of print].

Re-examining high reliability: actively organising for safety.

Sutcliffe KM, Paine L, Pronovost PJ. BMJ Qual Saf. 2016 Mar 21; [Epub ahead of print].

Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.

Robbins J, McAlearney AS. Am J Infect Control. 2016 Apr 26; [Epub ahead of print].

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward.

Aung TH, Beck AJ, Siese T, Berrisford R. BMJ Qual Improv Rep. 2016:28;5:1-4.

Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study.

van Rosse F, Suurmond J, Wagner C, de Bruijne M, Essink-Bot ML. BMJ Open. 2016;6:e009052.

Newspaper/Magazine Article

Clues to better health care from old malpractice lawsuits.

Landro L. Wall Street Journal. May 9, 2016.

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2016;21:1-4.

Web Resource

Attacking the Opioid Crisis Head On With Health IT.

Office of the National Coordinator for Health Information Technology.

NHS Improvement.

National Health Service England.

Meeting/Conference

Patient Safety and Healthcare Quality Improvement 2016.

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

Also of Note

The 18th Annual NPSF Patient Safety Congress.

National Patient Safety Foundation. May 23–25, 2016, Westin Kierland, Scottsdale, AZ.

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2016.

WebM&M Cases

Falling Through the Crack (in the Bedrails)

  • Spotlight Case
  • CME/CEU

Commentary by Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN

Multiple alarms went off in an ICU room after an intern and resident performed paracentesis on an older patient. Nurses found the patient confused and trying to get out of bed. She had pulled out her nasogastric and endotracheal tubes, her leg was stuck in the bedrails, and she had a large cut on her foot.

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Mismanagement of Delirium

Commentary by Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS

An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.

The Fluidity of Diagnostic "Wet Reads"

Commentary by Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD

An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.

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Perspectives on Safety

CLER and I-PASS

Interview

In Conversation With… Thomas J. Nasca, MD, MACP

Dr. Nasca is CEO of the Accreditation Council for Graduate Medical Education, the major accreditor of residency and fellowship training programs, and CEO of ACGME International. We spoke with him about ACGME's Clinical Learning Environment Review (CLER) program and its impact on medical education.

Interview

In Conversation With… Amy J. Starmer, MD, MPH

Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.

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Annual Perspectives 2015

Annual Perspective

Accountability in Patient Safety

Christopher Moriates, MD, and Robert M. Wachter, MD

While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.

Annual Perspective

Burnout Among Health Professionals and Its Effect on Patient Safety

Audrey Lyndon, PhD

Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.

Annual Perspective

Computerized Provider Order Entry and Patient Safety

Urmimala Sarkar, MD, and Kaveh Shojania, MD

Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.

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Did You Know?

Medication groups that trigger drug allergy alerts.

Source

Popular Content

WebM&M Cases

Mismanagement of Delirium

Commentary by Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS

Review

A systematic review of patient safety measures in adult primary care.

Hatoun J, Chan JA, Yaksic E, et al. Am J Med Qual. 2016 Apr 26; [Epub ahead of print].

WebM&M Cases

Falling Through the Crack (in the Bedrails)

Commentary by Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN

WebM&M Cases

Reaction to Dye

Commentary by Richard Cohan, MD

Study

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.

Cresswell KM, Mozaffar H, Lee L, Williams R, Sheikh A. BMJ Qual Saf. 2016 Apr 29; [Epub ahead of print].