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Journal Article

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study.

Dykes PC, Rozenblum R, Dalal A, et al. Crit Care Med. 2017 May 3; [Epub ahead of print].

Cost–benefit analysis of a support program for nursing staff.

Moran D, Wu AW, Connors C, et al. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

Quist AJL, Hickman TT, Amato MG, et al. Am J Health Syst Pharm. 2017;74:499-509.

The potential of collective intelligence in emergency medicine.

Kämmer JE, Hautz WE, Herzog SM, Kunina-Habenicht O, Kurvers RHJM. Med Decis Making. 2017 Mar 1; [Epub ahead of print].

Innovative use of the electronic health record to support harm reduction efforts.

Hyman D, Neiman J, Rannie M, Allen R, Swietlik M, Balzer A. Pediatrics. 2017;139:e20153410.

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit.

Solanki R, Mondal N, Mahalakshmy T, Bhat V. Arch Dis Child. 2017 May 3; [Epub ahead of print].

Introductions during time-outs: do surgical team members know one another's names?

Birnbach DJ, Rosen LF, Fitzpatrick M, Paige JT, Arheart KL. Jt Comm J Qual Patient Saf. 2017 Apr 18; [Epub ahead of print].

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Patient Hand-Off iNitiation and Evaluation (PHONE) study: a randomized trial of patient handoff methods.

Clanton J, Gardner A, Subichin M, et al. Am J Surg. 2017;213:299-306.


Leading a Culture of Safety: a Blueprint for Success.

Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017.

Rethinking Patient Safety.

Woodward S. Boca Raton, FL: Productivity Press; 2017. ISBN: 9781498778541.


Patient Safety Huddle.

VA National Center for Patient Safety.

Newspaper/Magazine Article

The last person you'd expect to die in childbirth.

Martin N, Montagne R. ProPublica and National Public Radio. May 12, 2017.

Special or Theme Issue

Patient Safety.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.


Improving Diagnosis in Health Care: An Implementation Workshop.

The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.

Also of Note

2017 QSEN National Forum: Going the Magnificent Mile With the QSEN Competencies

Quality Safety and Education for Nurses Institute. May 30–June 1, 2017; Swissôtel Chicago, Chicago IL.

Patient Safety Certificate Program.

Armstrong Institute for Patient Safety and Quality.June 12-16, 2017; Constellation Energy Building, Baltimore, MD.

WebM&M Cases

Diagnostic Delay in the Emergency Department

  • Spotlight Case

Commentary by Kyle Marshall, MD, and Hardeep Singh, MD, MPH

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

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Hemolysis Holdup

Commentary by Christopher M. Lehman, MD

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Communication Error in a Closed ICU

Commentary by Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

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Perspectives on Safety

Opioids and Patient Safety


In Conversation With… David Juurlink, MD, PhD

Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.


Opioid Overdose as a Patient Safety Problem

Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS

This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.

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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.

View all Annual Perspectives

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Did You Know?

Clinicians' recommended solutions for delayed diagnosis in primary care.


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Final Report of the Commission on Care.

Washington, DC: Commission on Care; June 2016.


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Ryan J. KUOW. National Public Radio. August 1, 2013.