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Journal Article

Implementation of the World Health Organization Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures.

Lashoher A, Schneider EB, Juillard C, et al. World J Surg. 2016 Oct 31; [Epub ahead of print].

A multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting.

Burlison JD, Quillivan RR, Kath LM, et al. J Patient Saf. 2016 Nov 3; [Epub ahead of print].

Feasibility and added value of Executive WalkRounds in long term care organizations in the Netherlands.

van Dusseldorp L, Huisman de Waal G, Hamers H, Westert G, Schoonhoven L. Jt Comm J Qual Patient Saf. 2016;42:545-557.

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Determining current insulin pen use practices and errors in the inpatient setting.

Brown KE, Hertig JB. Jt Comm J Qual Patient Saf. 2016;42:568-582.

Parents' perspectives on "keeping their children safe" in the hospital.

Rosenberg RE, Rosenfeld P, Williams E, et al. J Nurs Care Qual. 2016;31:318-326.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

Kruger JF, Chen AH, Rybkin A, et al. BMJ Qual Saf. 2016;25:977-985.

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.

Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations.

Thom KA, Heil EL, Croft LD, Duffy A, Morgan DJ, Johantgen M. J Interprof Care. 2016;30:819-822.

Sources and magnitude of error in preparing morphine infusions for nurse–patient controlled analgesia in a UK paediatric hospital.

Rashed AN, Tomlin S, Aguado V, Forbes B, Whittlesea C. Int J Clin Pharm. 2016;38:1069-1074.

Newspaper/Magazine Article

Is an indication-based prescribing system in our future?

ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.


ONC Health IT Certification Program: Enhanced Oversight and Accountability.

Federal Register. Washington, DC: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2016;81:72404-72471.

Web Resource

Just Bag It.

National Comprehensive Cancer Network.


Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.

Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.

Also of Note

28th Annual IHI National Forum on Quality Improvement in Health Care.

Institute for Healthcare Improvement. December 4–7, 2016; World Center Marriott, Orlando, FL. 

Reducing Workplace Violence With TeamSTEPPS.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. December 14, 2016; 1:00–2:00 PM (Eastern).

WebM&M Cases

Don't Dismiss the Dangerous: Obstetric Hemorrhage

  • Spotlight Case

Commentary by Elliott K. Main, MD

After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.

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Unexpected Drawbacks of Electronic Order Sets

Commentary by John D. McGreevey III, MD

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Continuity Errors in Resident Clinic

Commentary by Eric Warm, MD

After a motor vehicle collision, a patient with headaches and difficulty concentrating visited the internal medicine clinic. The covering resident diagnosed postconcussive syndrome and prescribed amitriptyline. The patient returned several days later with persistent symptoms. She saw a different resident, who ordered an MRI and referred her to neurology but mistakenly made the referral to the neuromuscular, rather than headache, clinic. With continued severe headaches, the patient returned a third time and saw her primary resident provider, who referred her to the correct neurology clinic.

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Perspectives on Safety

New Leaders in Safety and Quality


In Conversation With… Andrew Bindman, MD

Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.


In Conversation With… Derek Feeley

In January 2016, Mr. Feeley, a leading health care administrator from Scotland, became the third President and CEO of the Institute for Healthcare Improvement (IHI), probably the most influential organization of its kind. We spoke with him about his work at IHI to improve health care quality and safety.

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Did You Know?

Types of medication incidents affecting pediatric patients.


Popular Content


Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.

Feuerbacher RL, Funk KH, Spight DH, Diggs BS, Hunter JG. Arch Surg. 2012;147:1026-1030.


Safety culture and care: a program to prevent surgical errors.

Hemingway MW, O'Malley C, Silvestri S. AORN J. 2015;101:404-415.


Residents' response to duty-hour regulations—a follow-up national survey.

Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.


Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM).

Cooper S, Cant R, Porter J, et al. Resuscitation. 2010;81:446-452.

Newspaper/Magazine Article

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.