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Journal Article

The impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients.

Porat T, Delaney B, Kostopoulou O. BMC Med Inform Decis Mak. 2017;17:79.

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

Walker AS, Mason A, Quan TP, et al. Lancet. 2017 May 9; [Epub ahead of print].

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

Gilmartin-Thomas JF, Smith F, Wolfe R, Jani Y. Int J Nurs Stud. 2017;72:15-23.

Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.

Riblet N, Shiner B, Watts BV, Mills P, Rusch B, Hemphill RR. J Nerv Ment Dis. 2017;205:436-442.

State sepsis mandates—a new era for regulation of hospital quality.

Hershey TB, Kahn JM. N Engl J Med. 2017;376:2311-2313.

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies.

Kabadi SJ, Krishnaraj A. J Am Coll Radiol. 2017;14:459-466.

Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016.

Mitchell B, Cristancho S, Nyhof BB, Lingard LA. BMJ Qual Saf. 2017 Jun 3; [Epub ahead of print].

Interventions to improve oral chemotherapy safety and quality: a systematic review.

Zerillo JA, Goldenberg BA, Kotecha RR, Tewari AK, Jacobson JO, Krzyzanowska MK. JAMA Oncol. 2017 Jun 1; [Epub ahead of print].

Improving patient safety in handover from intensive care unit to general ward: a systematic review.

Wibrandt I, Lippert A. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.

Rao G, Epner P, Bauer V, Solomonides A, Newman-Toker DE. Diagnosis. 2017;4:67-72.

Web Resource

AHRQ Safety Program for Improving Surgical Care and Recovery.

Rockville, MD: Agency for Healthcare Research and Quality.

Newspaper/Magazine Article

Also of Note

Improving Diagnostic Accuracy Project 2016–2017.

Washington, DC: National Quality Forum; October 2016.

WebM&M Cases

The Perils of Contrast Media

  • Spotlight Case

Commentary by Umar Sadat, MD, PhD, and Richard Solomon, MD

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

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Chest Tube Complications

Commentary by Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Diagnostic Overshadowing Dangers

Commentary by Maria C. Raven, MD, MPH, MSc

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

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Perspectives on Safety

The Weekend Effect


In Conversation With… Paul Aylin, MBChB

Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.


The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?

Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS

This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.

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