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Journal Article

Early death after discharge from emergency departments: analysis of national US insurance claims data.

Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. BMJ. 2017;356:j239.

Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention.

Lawton R, O'Hara JK, Sheard L, et al. BMJ Qual Saf. 2017 Feb 3; [Epub ahead of print].

Reduction of incorrect record accessing and charting patient electronic medical records in the perioperative environment.

Rebello E, Kee S, Kowalski A, Harun N, Guindani M, Goravanchi F. Health Informatics J. 2016;22:1055-1062.

A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.

Leis JA, Shojania KG. BMJ Qual Saf. 2016 Dec 16; [Epub ahead of print].

Responsible e-prescribing needs e-discontinuation.

Fischer S, Rose A. JAMA. 2017;317:469-470.

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies.

Morrow KJ, Gustavson AM, Jones J. Int J Nurs Stud. 2016;64:42-51.

Year-end resident clinic handoffs: narrative review and recommendations for improvement.

Pincavage AT, Donnelly MJ, Young JQ, Arora VM. Jt Comm J Qual Patient Saf. 2017;43:71-79.

Teaching the diagnostic process as a model to improve medical education.

Sklar DP. Acad Med. 2017;92:1-4.

Web Resource

NAM Action Collaborative on Clinician Well-Being and Resilience.

Washington, DC: National Academy of Medicine.


A Framework for Safe, Reliable, and Effective Care.

Frankel A, Haraden C, Federico F, Lenoci-Edwards J. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017.


Sleep Deprivation, Health Care Providers, and Patient Safety.

National Patient Safety Foundation. February 27, 2017; 1:00–2:00 PM (Eastern).

Also of Note

2017 International Symposium on Human Factors and Ergonomics in Health Care: Improving the Outcomes.

Human Factors and Ergonomics Society. March 5–8, 2017; Sheraton New Orleans, New Orleans, Louisiana.

National Patient Safety Awareness Week.

National Patient Safety Foundation.

WebM&M Cases

The Hazards of Distraction: Ticking All the EHR Boxes

  • Spotlight Case

Commentary by Anthony C. Easty, PhD

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

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Safeguarding Diagnostic Testing at the Point of Care

Commentary by Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Refused Medication Error

Commentary by Mary Foley, PhD, RN

A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.

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Perspectives on Safety

Update on Teamwork


In Conversation With… Amy C. Edmondson, PhD, AM

Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.


New Insights About Team Training From a Decade of TeamSTEPPS

David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS

This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.

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Annual Perspectives

Annual Perspective

Patient Safety and Opioid Medications

Urmimala Sarkar, MD, and Kaveh Shojania, MD

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.

Annual Perspective

Rethinking Root Cause Analysis

Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD

Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.

View all Annual Perspectives

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Did You Know?

Factors associated with potentially preventable readmissions.


Popular Content


Pushing the profession: how the news media turned patient safety into a priority.

Millenson ML. Qual Saf Health Care. 2002;11:57-63.


Medication reconciliation at hospital discharge: evaluating discrepancies.

Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.


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.


Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

Roland D, Oliver A, Edwards ED, Mason BW, Powell CVE. Arch Dis Child. 2014;99:26-29.


Electronic Health Record Programs: Participation Has Increased, but Action Needed to Achieve Goals, Including Improved Quality of Care.

Washington, DC: United States Government Accountability Office; March 6, 2014. Publication GAO-14-207.