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Journal Article

Systematic review of the prevalence of medication errors resulting in hospitalization and death of nursing home residents.

Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2016 Nov 21; [Epub ahead of print].

Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method.

Stockwell DC, Bisarya H, Classen DC, et al. J Patient Saf. 2016;12:180-189.

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.

Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2016 Nov 18; [Epub ahead of print].

Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score?

Voepel-Lewis T, Malviya S, Tait AR. JAMA Pediatr. 2016 Nov 14; [Epub ahead of print].

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review.

Albutt AK, O'Hara JK, Conner MT, Fletcher SJ, Lawton RJ. Health Expect. 2016 Oct 26; [Epub ahead of print].

Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system.

Sage WM, Harding MC, Thomas EJ. Health Serv Res. 2016;51(suppl 3);2615-2633.

Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.

Larson DB, Donnelly LF, Podberesky DJ, Merrow AC, Sharpe RE Jr, Kruskal JB. Radiology. 2016 Sep 27; [Epub ahead of print].

The rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety.

Sax U, Lipprandt M, Röhrig R. Yearb Med Inform. 2016;1:130-137.

Remembering to learn: the overlooked role of remembrance in safety improvement.

Macrae C. BMJ Qual Saf. 2016 Nov 18; [Epub ahead of print].

Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

International Surgical Outcomes Study group. Br J Anaesth. 2016;117:601-609.

A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.

Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.

Special or Theme Issue

Unintended Consequences: New Problems and New Solutions.

Lehmann CU, Séroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.

Newspaper/Magazine Article

Zero tolerance for deadly hospital-acquired infections.

Levine H. Consumer Reports. November 21, 2016.


National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

D'Alton ME, Friedman AM, Smiley RM et al. J Obstet Gynecol Neonatal Nurs. 2016;45:706-717.


Getting the Board on Board: What Your Board Needs to Know About Quality and Safety, Third Edition.

Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.

Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.

Also of Note

TeamSTEPPS National Conference.

Agency for Healthcare Research and Quality. June 14–16, 2017; Hilton Cleveland Downtown, Cleveland, OH.

ACOG Committee Opinion #681: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2016;128:e257-e261.

WebM&M Cases

Suicidal Ideation in the Family Medicine Clinic

  • Spotlight Case

Commentary by Christine Moutier, MD

A young woman with a history of suicide attempts called her primary care physician's office in the morning saying that she had been cutting herself and had taken extra doses of medication. The receptionist scheduled the patient for an appointment late that afternoon. After the clinic visit, while awaiting transfer to the emergency department for evaluation and admission, the patient was left unattended and eloped before providers could evaluate her.

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One Dose, Two Errors

Commentary by Gregory A. Filice, MD

An older woman experienced acute kidney injury after being prescribed a nephrotoxic medication (amphotericin) intended for the ICU patient in the next bed. Caring for both patients, the covering resident entered the medication order for the wrong patient despite a policy requiring infectious disease consultation to prescribe IV amphotericin.

The Empty Bag

Commentary by Chris Vincent, PhD

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

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Perspectives on Safety

Root Cause Analysis: What Have We Learned?


In Conversation With... James P. Bagian, MD, PE

Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.


Errors and Near Misses: What Health Care Could Learn From Aviation

Carl Macrae, PhD

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

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