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Journal Article

Do work condition interventions affect quality and errors in primary care? Results from the Healthy Work Place Study.

Linzer M, Poplau S, Brown R, et al. J Gen Intern Med. 2016 Sep 9; [Epub ahead of print].

Computerized triggers of big data to detect delays in follow-up of chest imaging results.

Murphy DR, Meyer AND, Bhise V, et al. Chest. 2016;150:613-620.

Is there evidence for a better health care for cancer patients after a second opinion? A systematic review.

Ruetters D, Keinki C, Schroth S, Liebl P, Huebner J. J Cancer Res Clin Oncol. 2016;142:1521-1528.

Measurement of patient safety: a systematic review of the reliability and validity of adverse event detection with record review.

Hanskamp-Sebregts M, Zegers M, Vincent C, van Gurp PJ, de Vet HCW, Wollersheim H. BMJ Open. 2016;6:e011078.

Prevention by design: construction and renovation of health care facilities for patient safety and infection prevention.

Olmsted RN. Infect Dis Clin North Am. 2016;30:713-728.

Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: a systematic review and suggested taxonomy.

Bhamidipati VS, Elliott DJ, Justice EM, Belleh E, Sonnad SS, Robinson EJ. J Hosp Med. 2016;11:513-523.

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

Barry E, O'Brien K, Moriarty F, et al; PIPc Project Steering group. BMJ Open. 2016;6:e012079.

A model for the departmental quality management infrastructure within an academic health system.

Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2016 Sep 6; [Epub ahead of print].

Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.

Haag JD, Davis AZ, Hoel RW, et al. Am Health Drug Benefits. 2016;9:259-268.

Improving incident reporting among physician trainees.

Krouss M, Alshaikh J, Croft L, Morgan DJ. J Patient Saf. 2016 Sep 9; [Epub ahead of print].

Performing the wrong procedure.

Minnier T, Phrampus P, Waddell L. JAMA. 2016;316:1207-1208.

All CLEAR? Preparing for IT downtime.

Kashiwagi DT, Sexton MD, Souchet Graves CE, et al. Am J Med Qual. 2016 Aug 30; [Epub ahead of print].

Newspaper/Magazine Article

Surviving a bad diagnosis.

Hobson K. US News News and World Report. September 13, 2016.

Understanding human over-reliance on technology.

ISMP Medication Safety Alert! Acute Care Edition. September 8, 2016;21:1-4.

Also of Note

Patient Safety Project 2015–2017.

Washington, DC: National Quality Forum; December 2015.

John M. Eisenberg Patient Safety and Quality Award.

The Joint Commission and National Quality Forum.

WebM&M Cases

A Pill Organizing Plight

  • Spotlight Case

Commentary by Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Rosen, MD

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

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Complaints as Safety Surveillance

Commentary by Jennifer Morris and Marie Bismark, MD

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Wrong-Time Error With High-Alert Medication

Commentary by Annie Yang, PharmD, and Lewis Nelson, MD

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

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Perspectives on Safety

Telemedicine and Patient Safety


In Conversation With… Reed V. Tuckson, MD

Dr. Tuckson is President of the American Telemedicine Association. We spoke with him about telemedicine and patient safety.


Telemedicine and Patient Safety

Stephen Agboola, MD, MPH, and Joseph Kvedar, MD

This piece explores benefits and safety concerns associated with the increased adoption of telemedicine services.

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