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Journal Article

Prevalence and characteristics of physicians prone to malpractice claims.

Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. N Engl J Med. 2016;374:354-362.

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2016 Jan 6; [Epub ahead of print].

Associations between attending physician workload, teaching effectiveness, and patient safety.

Wingo MT, Halvorsen AJ, Beckman TJ, Johnson MG, Reed DA. J Hosp Med. 2016 Jan 6; [Epub ahead of print].

Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study).

Phatak A, Prusi R, Ward B, et al. J Hosp Med. 2016;11:39-44.

Engaging frontline staff in performance improvement: the American Organization of Nurse Executives implementation of Transforming Care at the Bedside collaborative.

Needleman J, Pearson ML, Upenieks VV, Yee T, Wolstein J, Parkerton M. Jt Comm J Qual Patient Saf. 2016;42:61-74.

Aviation and healthcare: a comparative review with implications for patient safety.

Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. JRSM Open. 2015;7:2054270415616548.

Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process.

Sheth S, McCarthy E, Kipps AK, et al. Pediatrics. 2016 Jan 7; [Epub ahead of print].

Incident and error reporting systems in intensive care: a systematic review of the literature.

Brunsveld-Reinders AH, Arbous MS, De Vos R, De Jonge E. Int J Qual Health Care. 2015 Dec 10; [Epub ahead of print].


Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.

US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.

Are Workarounds Ethical? Managing Moral Problems in Health Care Systems.

Berlinger N. New York, NY: Oxford University Press; 2016. ISBN: 9780190269296.

Newspaper/Magazine Article

Making checklists work: South Carolina's statewide experiment.

Rice S. Mod Healthc. January 23, 2016.

Reducing preventable harm in hospitals.

Bornstein D. New York Times. January 26, 2016.

Web Resource

2016 Culture of Safety.

American Nurses Association.


12th Annual Maryland Patient Safety Conference.

Maryland Patient Safety Center. March 18, 2016; Hilton Baltimore, Baltimore, MD.

Also of Note

How to Introduce TeamSTEPPS in Small and Rural Hospitals: The Yellow Brick Road of Teamwork.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. February 10, 2016; 1:00–2:00 PM (Eastern).

Applied Research Toward Zero Suicide Healthcare Systems (RO1).

Bethesda, MD: National Institute of Mental Health; December 11, 2015. Funding Opportunity Announcement No. RFA-MH-16-800.

WebM&M Cases

A Room Without Orders

  • Spotlight Case

Commentary by Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN

Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.

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New Patient Mistakenly Checked in as Another

Commentary by Robert A. Green, MD, MPH, and Jason Adelman, MD, MS

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Inadvertent Use of More Potent Acid Leads to Burn

Commentary by Howard I. Maibach, MD

An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.

View all WebM&M Cases

Perspectives on Safety

Update on Diagnostic Errors


In Conversation With… Mark L. Graber, MD

Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.


Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice

Hardeep Singh, MD, MPH

This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.

View all Perspectives

WebM&M is now on PSNet

AHRQ has merged Patient Safety Network (PSNet) and WebM&M (Morbidity and Mortality Rounds on the Web) for a more streamlined experience. Learn more.

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Did You Know?

Errors reported in patients receiving radiation therapy.


Popular Content


An evaluation of parenteral nutrition errors in an era of drug shortages.

Storey MA, Weber RJ, Besco K, Beatty S, Aizawa K, Mirtallo JM. Nutr Clin Pract. 2015 Oct 27; [Epub ahead of print].

WebM&M Cases

Overdose on Oxygen?

Commentary by B. Ronan O'Driscoll, MD


Prevalence and characteristics of physicians prone to malpractice claims.

Studdert DM, Bismark MM, Mello MM, Singh H, Spittal MJ. N Engl J Med. 2016;374:354-362.


National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2015.


Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2016 Jan 7; [Epub ahead of print].