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Journal Article

Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.

Lin LA, Bohnert AS, Kerns RD, Clay MA, Ganoczy D, Ilgen MA. Pain. 2017 Jan 4; [Epub ahead of print].

Large-scale implementation of the I-PASS handover system at an academic medical centre.

Shahian DM, McEachern K, Rossi L, Chisari RG, Mort E. BMJ Qual Saf. 2017 Mar 9; [Epub ahead of print].

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

Guise JM, Hansen M, O'Brien K, et al. BMJ Open. 2017;7:e014057.

Ordering interruptions in a tertiary care center: a prospective observational study.

Dadlez NM, Azzarone G, Sinnett MJ, et al. Hosp Pediatr. 2017;7:134-139.

A learning health care system using computer-aided diagnosis.

Cahan A, Cimino JJ. J Med Internet Res. 2017;19:e54.

What is known: examining the empirical literature in resident work hours using 30 influential articles.

Philibert I. J Grad Med Educ. 2016;8:795-805.

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

Trbovich P, Shojania KG. BMJ Qual Saf. 2017 Feb 21; [Epub ahead of print].

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

Schreiber R, Sittig DF, Ash J, Wright A. J Am Med Inform Assoc. 2017 Feb 16; [Epub ahead of print].

The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study.

Han K, Bohnen JD, Peponis T, et al. J Am Coll Surg. 2017 Jan 16; [Epub ahead of print].

Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers.

Myers JS, Tess AV, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017 Feb 6; [Epub ahead of print].

Tools/Toolkit

Patient and Family Engagement in Primary Care.

Rockville, MD: Agency for Healthcare Research and Quality; March 2017.

Meeting/Conference

Implementing CQI Programs: A Roadmap to Quality Improvement.

Institute for Safe Medication Practices. April 9, 2017; Maggiano's Little Italy, Philadelphia, PA.

Patient Safety: A Practical Approach From CPS Experts.

Missouri Center for Patient Safety. April 4, 2017; 1:00–2:00 PM (Eastern).

Also of Note

Common Program Requirements. The Learning and Working Environment (Duty Hours).

Accreditation Council for Graduate Medical Education.

Teams Saving Brains One Minute at a Time.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. April 12, 2017; 1:00–2:00 PM (Eastern).

WebM&M Cases

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU

Commentary by Daniel J. Morgan, MD, MS, and Andrew Foy, MD

Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.

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Diagnosing a Missed Diagnosis

Commentary by James B. Reilly, MD, MS, and Christopher Webster, DO

A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

Commentary by Scott D. Nelson, PharmD, MS

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

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Perspectives on Safety

Approaching Safety Culture in New Ways

Interview

In Conversation With… Mary Dixon-Woods, MPhil

Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.

Perspective

Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety

Sara J. Singer, MBA, PhD

This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.

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Annual Perspectives

Annual Perspective

Measuring and Responding to Deaths From Medical Errors

Sumant Ranji, MD

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

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.

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