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Journal Article

Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.

Mozaffar H, Cresswell KM, Williams R, Bates DW, Sheikh A. BMJ Qual Saf. 2017 Feb 7; [Epub ahead of print].

Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation.

Kostopoulou O, Porat T, Corrigan D, Mahmoud S, Delaney BC. Br J Gen Pract. 2017 Jan 30; [Epub ahead of print].

The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.

Ratanawongsa N, Chan LLS, Fouts MM, Murphy EJ. J Diabetes Res. 2017;2017:8983237.

Addressing physician burnout: the way forward.

Shanafelt TD, Dyrbye LN, West CP. JAMA. 2017 Feb 9; [Epub ahead of print].

Medication safety in the operating room: literature and expert-based recommendations.

Wahr JA, Abernathy JH III, Lazarra EH, et al. Br J Anaesth. 2017;118:32-43.

Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness.

Dankbaar MEW, Richters O, Kalkman CJ, et al. BMC Med Educ. 2017;17:30.

Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative.

Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Am J Infect Control. 2017;45:13-16.

Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes.

Keebler JR, Lazzara EH, Patzer BS, et al. Hum Factors. 2016;58:1187-1205.

Monitoring teamwork: a narrative review.

Rutherford JS. Anaesthesia. 2017;72(suppl 1):84-94.

Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors.

Dreisinger N, Zapolsky N. Pediatr Emerg Care. 2017;33:128-131.

Putting knowledge into practice: does information on adverse drug interactions influence people's dosing behaviour?

Dohle S, Dawson IGJ. Br J Health Psychol. 2017 Feb 3; [Epub ahead of print].

Newspaper/Magazine Article


Long Term Care PSO 101—What You Should Know.

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

Also of Note

High Reliability Organizational Culture using Standardized Patient Simulation and TeamSTEPPS.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. March 8, 2017; 1:00–2:00 PM (Eastern).

Improving Diagnostic Accuracy Project 2016–2017.

Washington, DC: National Quality Forum; October 2016.

WebM&M Cases

The Hazards of Distraction: Ticking All the EHR Boxes

  • Spotlight Case

Commentary by Anthony C. Easty, PhD

A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.

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Safeguarding Diagnostic Testing at the Point of Care

Commentary by Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Refused Medication Error

Commentary by Mary Foley, PhD, RN

A man with end-stage renal disease was admitted with acute renal failure and mental status changes. The patient refused to take his lactulose owing to loose stools. Although nursing staff noted the refusal in the medical record, they did not inform his primary team. When the patient became more confused, a nurse alerted the team but did not describe the missed doses of lactulose. The patient continued to decline and was transferred to the ICU.

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Perspectives on Safety

Update on Teamwork


In Conversation With… Amy C. Edmondson, PhD, AM

Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.


New Insights About Team Training From a Decade of TeamSTEPPS

David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS

This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.

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Annual Perspectives

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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