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Journal Article

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

Yadav S, Kazanji N, Narayan KC, et al. J Am Med Inform Assoc. 2016 Jun 29; [Epub ahead of print].

State legal restrictions and prescription-opioid use among disabled adults.

Meara E, Horwitz JR, Powell W, et al. N Engl J Med. 2016;375:44-53.

Assessing the relationship between patient safety culture and EHR strategy.

Ford EW, Silvera GA, Kazley AS, Diana ML, Huerta TR. Int J Health Care Qual Assur. 2016;29:614-627.

Peer support for clinicians: a programmatic approach.

Shapiro J, Galowitz P. Acad Med. 2016 Jun 28; [Epub ahead of print].

Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability.

Manaseki-Holland S, Lilford RJ, Bishop JRB, et al; UK Case Note Review Group. BMJ Qual Saf. 2016 Jun 22; [Epub ahead of print].

Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program.

Zemaitis CT, Morris G, Cabie M, Abdelghany O, Lee L. Hosp Pharm. 2016;51:468-473.

Systematic review and meta-analysis of educational interventions designed to improve medication administration skills and safety of registered nurses.

Härkänen M, Voutilainen A, Turunen E, Vehviläinen-Julkunen K. Nurse Educ Today. 2016;41:36-43.

RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: a national cross-sectional study of acute-care hospitals.

Smeds-Alenius L, Tishelman C, Lindqvist R, Runesdotter S, McHugh MD. Int J Nurs Stud. 2016;61:117-124.

Outcomes are worse in US patients undergoing surgery on weekends compared with weekdays.

Glance LG, Osler T, Li Y, et al. Med Care. 2016;54:608-615.


Drug Shortages: Certain Factors Are Strongly Associated With This Persistent Public Health Challenge.

Washington, DC: United States Government Accountability Office; July 7, 2016. Publication GAO-16-595.

Sustaining Improvement.

Scoville R, Little K, Rakover J, Luther K, Mate K. Cambridge, MA: Institute for Healthcare Improvement; 2016.

Newspaper/Magazine Article

Using the web or an app instead of seeing a doctor? Caution is advised.

Frakt A. New York Times. July 11, 2016.

Feasibility of preventable readmission rate as a quality measure.

Soong C. National Quality Measures Clearinghouse: Expert Commentaries; June 20, 2016.


Speak Up for Patient Safety: Communicating Before, During and After an Adverse Event.

Oregon Patient Safety Commission. August 19, 2016; OMEF Event Center, Portland, OR.

Also of Note

Patient Safety Project 2015–2017.

Washington, DC: National Quality Forum; December 2015.

Diagnostic Error in Medicine 9th International Conference.

Society to Improve Diagnosis in Medicine. November 6–8, 2016; Loews Hollywood Hotel, Los Angeles, CA.

TeamSTEPPS in Office-based Care: Master Training.

Agency for Healthcare Research and Quality, Health Research & Educational Trust. August 10–September 19, 2016.

WebM&M Cases

The Case of Mistaken Intubation

  • Spotlight Case

Commentary by Maria J. Silveira, MD, MA, MPH

An older man with multiple medical conditions was found hypoxic, hypotensive, and tachycardic. He was taken to the hospital. Providers there were unable to determine the patient's wishes for life-sustaining care, and, unaware that he had previously completed a DNR/DNI order, they placed him on a mechanical ventilator.

Take CME Quiz

July Syndrome

Commentary by John Q. Young, MD, MPP

Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.

Communication With Consultants

Commentary by Steven L. Cohn, MD

When a pregnant woman with fever, nausea, and headaches presented to the emergency department (ED), laboratory tests showed an incredibly high white blood cell count. Although the ED contacted the hematology service for a consultation, the urgency of the patient's clinical status was not conveyed, leading to a fatal delay in diagnosing and treating her acute myeloid leukemia.

View all WebM&M Cases

Perspectives on Safety

Certification in Patient Safety


In Conversation With… Gregg S. Meyer, MD, MSc

Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.


Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective

Karen Frank, DNP, RN, MSHA

This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.


Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective

Zahra Khudeira, PharmD

In this piece, a pharmacist highlights the importance of earning patient safety certification.

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Did You Know?

Consequences of oversight in physical examination.


Popular Content


Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.


Medication reconciliation at hospital discharge: evaluating discrepancies.

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

Newspaper/Magazine Article

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.


Balancing just culture with regulatory standards.

Gorzeman J. Nurs Adm Q. 2008;32:308-311.


Integrating computerized clinical decision support systems into clinical work: a meta-synthesis of qualitative research.

Miller A, Moon B, Anders S, Walden R, Brown S, Montella D. Int J Med Inform. 2015;84:1009-1018.