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Journal Article

Communicating findings of delayed diagnostic evaluation to primary care providers.

Meyer AND, Murphy DR, Singh H. J Am Board Fam Med. 2016;29:469-473.

Cultural transformation after implementation of crew resource management: is it really possible?

Hefner JL, Hilligoss B, Knupp A, et al. Am J Med Qual. 2016 Jul 15; [Epub ahead of print].

Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials.

Clyne B, Fitzgerald C, Quinlan A, et al. J Am Geriatr Soc. 2016;64:1210-1222.

Risk factors for i.v. compounding errors when using an automated workflow management system.

Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73:887-893.

Frequency of passive EHR alerts in the ICU: another form of alert fatigue?

Kizzier-Carnahan V, Artis KA, Mohan V, Gold JA. J Patient Saf. 2016 Jun 22; [Epub ahead of print].

Do physicians clean their hands? Insights from a covert observational study.

Kovacs-Litman A, Wong K, Shojania KG, Callery S, Vearncombe M, Leis JA. J Hosp Med. Jul 5 2016; [Epub ahead of print].

Diagnosis is a team sport—partnering with allied health professionals to reduce diagnostic errors: a case study on the role of a vestibular therapist in diagnosing dizziness.

Thomas DB, Newman-Toker DE. Diagnosis. 2016;3:49-59.

Surgeons' disclosures of clinical adverse events.

Elwy AR, Itani KMF, Bokhour BG, et al. JAMA Surg. 2016 Jul 20; [Epub ahead of print].

Access to prescription opioids—Primum Non Nocere: a teachable moment.

Tyler PD, Larochelle MR, Mafi JN. JAMA Inter Med. 2016 Jul 18; [Epub ahead of print].

Exploring approaches to patient safety: the case of spinal manipulation therapy.

Rozmovits L, Mior S, Boon H. BMC Complement Altern Med. 2016;16:164.

Book/Report

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.

A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.

Legislation/Regulation

Newspaper/Magazine Article

Correct use of inhalers: help patients breathe easier.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2016;21:1-6.

Meeting/Conference

Second Victim Train-the-Trainer Workshop.

Center for Patient Safety and University of Missouri. November 7, 2016; Saint Luke's North Hospital, Barry Road, Kansas City, MO.

Also of Note

Become a Patient Safety Trainer Conference—Canada.

Canadian Patient Safety Institute. August 8–9, 2016. Queens University, Kingston ON.

Family Centered Patient Advocacy Training.

Pulse of New York. August 3–17, 2016; 5:30–8:30 PM (Eastern); 3601 Hempstead Tpk, Levittown, NY.

WebM&M Cases

Cognitive Overload in the ICU

  • Spotlight Case
  • CME/CEU

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

Interview

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.

Perspective

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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