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Journal Article

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards.

Pannick S, Archer S, Johnston MJ, et al. BMJ Open. 2017;7:e014401.

New persistent opioid use after minor and major surgical procedures in US adults.

Brummett CM, Waljee JF, Goesling J, et al. JAMA Surg. 2017 Apr 12; [Epub ahead of print].

Measurement as a performance driver: the case for a national measurement system to improve patient safety.

Krause TR, Bell KJ, Pronovost P, Etchegaray JM. J Patient Saf. 2017 Apr 4; [Epub ahead of print].

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. J Am Med Inform Assoc. 2017;24:413-422.

Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout.

Dyrbye LN, Trockel M, Frank E, et al. Ann Intern Med. 2017 Apr 18; [Epub ahead of print].

Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study.

Grigg EB, Martin LD, Ross FJ, et al. Anesth Analg. 2017 Jan 11; [Epub ahead of print].

Hiding in plain sight—resurrecting the power of inspecting the patient.

Gupta S, Saint S, Detsky AS. JAMA Intern Med. 2017 Apr 17; [Epub ahead of print].

Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria.

Frankenthal D, Israeli A, Caraco Y, et al. J Am Geriatr Soc. 2017;65:e33-e38.

Measuring to improve medication reconciliation in a large subspecialty outpatient practice.

Kern E, Dingae MB, Langmack EL, Juarez C, Cott G, Meadows SK. Jt Comm J Qual Patient Saf. 2017 Mar 29; [Epub ahead of print].

Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.

Moonen PJ, Mercelina L, Boer W, Fret T. Scand J Trauma Resusc Emerg Med. 2017;25:13.

A growth mindset approach to preparing trainees for medical error.

Klein J, Delany C, Fischer MD, Smallwood D, Trumble S. BMJ Qual Saf. 2017 Apr 11; [Epub ahead of print].

Book/Report

Impact of Medical Errors and Malpractice on Health Economics, Quality, and Patient Safety.

Riga M, ed. Hershey, PA: IGI Global; 2017. ISBN: 9781522523376.

Newspaper/Magazine Article

A boy's life is lost to sepsis. Thousands are saved in his wake.

Dwyer J. New York Times. April 13, 2017.

Web Resource

Medication Without Harm: WHO's Third Global Patient Safety Challenge.

Geneva, Switzerland: World Health Association.

Meeting/Conference

ACS Quality and Safety Conference.

American College of Surgeons. July 21–24, 2017; New York Hilton Midtown, New York, NY.

Also of Note

Presenting TeamSTEPPS in the Perioperative Setting.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).

2017 Northwest Patient Safety Conference.

Washington Patient Safety Coalition. May 11, 2017; Seattle Airport Marriott, Seatac, WA.

WebM&M Cases

Engaging Seriously Ill Older Patients in Advance Care Planning

  • Spotlight Case
  • CME/CEU

Commentary by Daren K. Heyland, MD, MSc

When a 94-year-old woman presented for routine primary care, the intern caring for her discovered that the patient's code status was "full code" and that there was no documentation of discussions regarding her wishes for end-of-life care. The intern and his supervisor engaged the patient in an advance care planning discussion, during which she clarified that she would not want resuscitation or life-prolonging measures.

Take CME Quiz

Patient Allergies and Electronic Health Records

Commentary by Matthew J. Doyle, MBBS

Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

Commentary by Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

View all WebM&M Cases

Perspectives on Safety

New Thinking About High Reliability

Interview

In Conversation With… Mark Chassin, MD, MPP, MPH

Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.

Interview

In Conversation With… Kathleen Sutcliffe, MSN, PhD

Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.

View all Perspectives

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?

Factors associated with potentially preventable readmissions.

Source

Popular Content

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The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

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Study

Medication reconciliation at hospital discharge: evaluating discrepancies.

Wong JD, Bajcar JM, Wong GG, et al. Ann Pharmacother. 2008;42:1373-1379.

Newspaper/Magazine Article

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.

Commentary

'Clean Care is Safer Care': the Global Patient Safety Challenge 2005-2006.

Pittet D, Allegranzi B, Storr J, Donaldson L. Int J Infect Dis. 2006;10:419-24.

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Computerised provider order entry and residency education in an academic medical centre.

Wong B, Kuper A, Robinson N, et al. Med Educ. 2012;46:795-806.