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Journal Article

Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records.

Kirkendall ES, Kouril M, Dexheimer JW, et al. J Am Med Inform Assoc. 2016 Aug 9; [Epub ahead of print].

Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.

Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. PLoS One. 2016;11:e0160075.

Healthcare staff wellbeing, burnout, and patient safety: a systematic review.

Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. PLoS One. 2016;11:e0159015.

JAMA professionalism: disclosure of medical error.

Levinson W, Yeung J, Ginsburg S. 2016;316:764-765.

A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions.

Mathew R, Gundy S, Ulic D, Haider S, Wasi P. Acad Med. 2016 Jul 26; [Epub ahead of print].

The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.

Inaba K, Okoye O, Aksoy H, et al. Ann Surg. 2016 Jul 18; [Epub ahead of print].

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2016 Aug 16; [Epub ahead of print].

A framework to assess patient-reported adverse outcomes arising during hospitalization.

Barbara O, Jose SM, Jayna HL, et al. BMC Health Serv Res. 2016;16:357.

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture.

Lee SH, Phan PH, Dorman T, Weaver SJ, Pronovost PJ. BMC Health Serv Res. 2016;16:254.

Newspaper/Magazine Article


Avoiding Unconscious Bias: a Guide for Surgeons.

London, UK: Royal College of Surgeons of England; 2016.


The Role of Standards in Managing & Mitigating Health IT Patient Safety Risks.

National Institute of Standards and Technology. September 7, 2016; NIST Red Auditorium, Gaithersburg, MD.

Also of Note

Preventing Overdiagnosis.

Agency for Health Quality and Assessment of Catalonia, Dartmouth Institute, British Medical Journal, Bond University, Centre for Evidence-Based Medicine, and Consumer Reports. September 20–22, 2016; Barcelona International Convention Centre, Barcelona, Spain.

ASHRM 2016 Annual Conference.

American Society for Healthcare Risk Management. September 25–28, 2016; Orange County Convention Center, Orlando, FL.

WebM&M Cases

Cognitive Overload in the ICU

  • Spotlight Case

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


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.


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?

Medication groups that trigger drug allergy alerts.


Popular Content

Multi-use Website

Preventing Falls With Injury.

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


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.

Government Resource

Medical Office Survey on Patient Safety Culture: 2014 User Comparative Database Report.

Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. Report No. 14-0032-EF.

Audiovisual Presentation

The Commonwealth Fund Quality Improvement Colloquium: Patient Safety Five Years After To Err Is Human.

Washington, DC: The National Academy of Sciences; November 4-5, 2004.

Newspaper/Magazine Article

Pharmacists play key role in patient safety.

DukeMed News [serial online]. January 8, 2005.