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Journal Article

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Estimating deaths due to medical error: the ongoing controversy and why it matters.

Shojania KG, Dixon-Woods M. BMJ Qual Saf. 2016 Oct 12; [Epub ahead of print].

Errors, omissions, and outliers in hourly vital signs measurements in intensive care.

Maslove DM, Dubin JA, Shrivats A, Lee J. Crit Care Med. 2016;44:e1021-e1030.

The application of the Global Trigger Tool: a systematic review.

Hibbert PD, Molloy CJ, Hooper TD, et al. Int J Qual Health Care. 2016 Sep 24; [Epub ahead of print].

Ethical considerations in the development of the flexibility in duty hour requirements for surgical trainees trial.

Minami CA, Odell DD, Bilimoria KY. JAMA Surg. 2016 Oct 12; [Epub ahead of print].

A national physician survey of diagnostic error in paediatrics.

Perrem LM, Fanshawe TR, Sharif F, Plüddemann A, O'Neill MB. Eur J Pediatr. 2016;175:1387-1392.

Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study.

Ning HC, Lin CN, Chiu DTY, et al. PLoS One. 2016;11:e0160821.

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.

Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu AW. BMJ Open. 2016;6:e011708.

Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine.

Singh H, Zwaan L. Ann Intern Med. 2016;165:HO2-HO4.

Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections.

Richter JP, McAlearney AS. Health Care Manage Rev. 2016 Aug 15; [Epub ahead of print].


Newspaper/Magazine Article


Funding Announcement for Projects Targeting the Reduction of Healthcare-Associated Infections.

Rockville, MD: Agency for Healthcare Research and Quality; October 13, 2016. PA-17-007 and PA-17-008.


Using Just Culture to Improve Results on the AHRQ Hospital Survey on Patient Safety Culture.

Agency for Healthcare Research and Quality. November 9, 2016; 1:00–2:00 PM (Eastern).

Also of Note

Diagnostic Error in Medicine 9th International Conference.

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

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

Unintended Consequences of CPOE

  • Spotlight Case

Commentary by Robert L. Wears, MD, PhD

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

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Lapse in Antibiotics Leads to Sepsis

Commentary by Mitchell Levy, MD

Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.

Near Miss With Neonate

Commentary by Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN

A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.

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Perspectives on Safety

Big Data and Patient Safety


In Conversation With… Richard Platt, MD, MSc

Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. We spoke with him about big data and patient safety.


Health Care Data Science for Quality Improvement and Patient Safety

Alvin Rajkomar, MD

This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.

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