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Journal Article

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders.

Abraham J, Kannampallil TG, Jarman A, et al. BMJ Qual Saf. 2017 Jul 11; [Epub ahead of print].

Non–health care facility medication errors resulting in serious medical outcomes.

Hodges NL, Spiller HA, Casavant MJ, Chounthirath T, Smith GA. Clin Toxicol (Phila). 2017 Jul 10; [Epub ahead of print].

Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.

Frank JW, Lovejoy TI, Becker WC, et al. Ann Intern Med. 2017 Jul 18; [Epub ahead of print].

Surgical residents' work hours and well-being in year 2 of the FIRST trial.

Dahlke AR, Quinn CM, Chung JW, Bilimoria KY. N Engl J Med. 2017;377:192-194.

Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: a cluster-randomized trial.

Liebschutz JM, Xuan Z, Shanahan CW, et al. JAMA Intern Med. 2017 Jul 17; [Epub ahead of print].

Preoperative site marking: are we adhering to good surgical practice?

Bathla S, Chadwick M, Nevins EJ, Seward J. J Patient Saf. 2017 Jun 29; [Epub ahead of print].

Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.

Strudwick G, Reisdorfer E, Warnock C, et al. J Nurs Care Qual. 2017 Jun 27; [Epub ahead of print].

The association between patient safety indicators and medical malpractice risk: evidence from Florida and Texas.

Black BS, Wagner AR, Zabinski Z. Am J Health Econ. 2017;3:109-139.

Special or Theme Issue

Three perspectives on changes in resident work environment and duty hours.

Bilimoria KY, Meyers MO, Mouawad NJ, et al. JAMA Surg. 2017 Jul 5; [Epub ahead of print].

Web Resource

AHRQ Safety Program for Improving Antibiotic Use.

Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, University of Chicago.

Newspaper/Magazine Article

Double-booked: when surgeons operate on two patients at once.

Boodman SG. Kaiser Health News. July 12, 2017.


Diagnosis: Interpreting the Shadows.

Croskerry P, Cosby K, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.


Replacing Old Practices With New Paradigms: Adopting Safe Practices for IV Push Medications.

Institute for Safe Medication Practices. September 12, 2017; 1:30–3:00 PM (Eastern).

Also of Note

International Forum on Quality & Safety in Healthcare: Asia.

British Medical Journal, Institute for Healthcare Improvement. August 24–26, 2017, Kuala Lumpur, Malaysia.

ISMP QuarterWatch Reports.

Horsham, PA: Institute for Safe Medication Practices.

WebM&M Cases

Pseudo-obstruction But a Real Perforation

  • Spotlight Case

Commentary by Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

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Delayed Recognition of a Positive Blood Culture

Commentary by Sarah Doernberg, MD, MAS

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

The Hidden Harms of Hand Sanitizer

Commentary by Stephen Stewart, MBChB, PhD

Hospitalized for pneumonia, a woman with a history of alcohol abuse and depression was found unconscious on the medical ward. A toxicology panel revealed her blood alcohol level was elevated at 530 mg/dL. A search of the ward revealed several empty containers of alcoholic foam sanitizer, which the patient confessed to ingesting.

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Perspectives on Safety

Legal Issues and Patient Safety


In Conversation With… Michelle Mello, MPhil, JD, PhD

Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.


Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know?

David Studdert, LLB, ScD

This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

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