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Journal Article

Toward a safer health care system: the critical need to improve measurement.

Jha A, Pronovost PJ. JAMA. 2016 Apr 14; [Epub ahead of print].

Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.

Cresswell KM, Mozaffar H, Lee L, Williams R, Sheikh A. BMJ Qual Saf. 2016 Apr 1; [Epub ahead of print].

Exclusion of residents from surgery-intensive care team communication: a qualitative study.

Gotlib Conn L, Haas B, Rubenfeld GD, et al. J Surg Educ. 2016 Mar 15; [Epub ahead of print].

Digital health and patient safety.

Agboola SO, Bates DW, Kvedar JC. JAMA. 2016;315:1697-1698.

Five topics health care simulation can address to improve patient safety: results from a consensus process.

Sollid SJM, Dieckman P, Aase K, Søreide E, Ringsted C, Østergaard D. J Patient Saf. 2016 Mar 28; [Epub ahead of print].

Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study.

Zucker J, Mittal J, Jen SP, Cheng L, Cennimo D. Pharmacotherapy. 2016;36:245-251.

Learning from incidents in healthcare: the journey, not the arrival, matters.

Leistikow I, Mulder S, Vesseur J, Robben P. BMJ Qual Saf. 2016 Apr 1; [Epub ahead of print].

Improving feedback on junior doctors' prescribing errors: mixed-methods evaluation of a quality improvement project.

Reynolds M, Jheeta S, Benn J, et al. BMJ Qual Saf. 2016 Apr 4; [Epub ahead of print].

Inpatient housestaff discontinuity of care and patient adverse events.

Fletcher KE, Singh S, Schapira MM, et al. Am J Med. 2016;129:341-347.e21.

Using simulation to identify sources of medical diagnostic error in child physical abuse.

Anderst J, Nielsen-Parker M, Moffatt M, Frazier T, Kennedy C. Child Abuse Negl. 2016;52:62-69.


When There's Harm in the Hospital: Can Transparency Replace "Deny and Defend"?

National Health Policy Forum. Washington, DC: George Washington University. March 11, 2016.

Newspaper/Magazine Article

Surgeons must tell patients of double-booked surgeries, new guidelines say.

Abelson J, Staltzman J. Boston Globe. April 13, 2016.

Nurses say stress interferes with caring for their patients.

Yu A. Health Shots. National Public Radio. April 15, 2016.

Future directions for diagnostic decision support.

Carr S. ImproveDx. April 2016;3:1-3.

Also of Note

Save Lives: Clean Your Hands.

World Alliance for Patient Safety.

TeamSTEPPS 2.0 Master Training Workshop.

University of Texas Health Science Center. May 5–6, 2016; UT Health Science Center San Antonio, San Antonio, TX.

Perspectives on Safety



In Conversation With… Thomas J. Nasca, MD, MACP

Dr. Nasca is CEO of the Accreditation Council for Graduate Medical Education, the major accreditor of residency and fellowship training programs, and CEO of ACGME International. We spoke with him about ACGME's Clinical Learning Environment Review (CLER) program and its impact on medical education.


In Conversation With… Amy J. Starmer, MD, MPH

Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.

View all Perspectives

WebM&M Cases

Dropping to New Lows

  • Spotlight Case

Commentary by Patricia Juang, MD, and Kristen Kulasa, MD

While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.

Take CME Quiz

Lost in Sign Out and Documentation

Commentary by Michael E. Detsky, MD, MSc

During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.

Situational Awareness and Patient Safety

Commentary by Jeanne M. Farnan, MD, MHPE

A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.

View all WebM&M Cases

Annual Perspectives 2015

Annual Perspective

Accountability in Patient Safety

Christopher Moriates, MD, and Robert M. Wachter, MD

While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.

Annual Perspective

Burnout Among Health Professionals and Its Effect on Patient Safety

Audrey Lyndon, PhD

Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.

Annual Perspective

Computerized Provider Order Entry and Patient Safety

Urmimala Sarkar, MD, and Kaveh Shojania, MD

Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.

View all Annual Perspectives

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Did You Know?

Hospital-acquired severe sepsis associated with higher hospitalization costs.


Popular Content

WebM&M Cases

Overdose on Oxygen?

Commentary by B. Ronan O'Driscoll, MD


Toward a safer health care system: the critical need to improve measurement.

Jha A, Pronovost PJ. JAMA. 2016 Apr 14; [Epub ahead of print].

WebM&M Cases

Reaction to Dye

Commentary by Richard Cohan, MD


National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; 2016.


Exclusion of residents from surgery-intensive care team communication: a qualitative study.

Gotlib Conn L, Haas B, Rubenfeld GD, et al. J Surg Educ. 2016 Mar 15; [Epub ahead of print].