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Journal Article

Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health.

Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Ann Intern Med. 2017 Aug 1; [Epub ahead of print].

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

Molina G, Berry WR, Lipsitz SR, et al. Ann Surg. 2017 Jun 27; [Epub ahead of print].

Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors.

Hickman TT, Quist AJL, Salazar A, et al. BMJ Qual Saf. 2017 Jul 28; [Epub ahead of print].

Time for transparent standards in quality reporting by health care organizations.

Pronovost PJ, Wu AW, Austin JM. JAMA. 2017 Aug 7; [Epub ahead of print].

Intraoperative surgical performance measurement and outcomes: choose your tools carefully.

Aggarwal R. JAMA Surg. 2017 Aug 9; [Epub ahead of print].

Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data.

Quinn GR, Ranum D, Song E, et al. Jt Comm J Qual Patient Saf. 2017 Jun 26; [Epub ahead of print].

The relationship between patient safety climate and occupational safety climate in healthcare—a multi-level investigation.

Pousette A, Larsman P, Eklöf M, Törner M. J Safety Res. 2017;61:187-198.

Challenging authority during an emergency—the effect of a teaching intervention.

Friedman Z, Perelman V, McLuckie D, et al. Crit Care Med. 2017;45:e814-e820. 

Using simulation to improve systems-based practices.

Gardner AK, Johnston M, Korndorffer JR Jr, Haque I, Paige JT. Jt Comm J Qual Patient Saf. 2017 Jul 19; [Epub ahead of print].

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use.

Morgan DJ, Malani P, Diekema DJ. JAMA. 2017 Jul 31; [Epub ahead of print].


Optimal Resources for Surgical Quality and Safety.

Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.


Health Literacy Tools for Providers of Medication Therapy Management.

Rockville, MD: Agency for Healthcare Research and Quality.

Newspaper/Magazine Article


Opioid Stewardship Across the Care Continuum.

Armstrong Institute for Patient Safety and Quality. September 25, 2017; The Johns Hopkins Hospital, Baltimore, MD.

WebM&M Cases

Despite Clues, Failed to Rescue

  • Spotlight Case

Commentary by Amir A. Ghaferi, MD, MS

Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.

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Add-on Case and the Missing Checklist

Commentary by Ken Catchpole, PhD

Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.

Point-of-care Mixup: 1 Shot Turns Into 3

Commentary by F. Ralph Berberich, MD

A 2-month-old boy brought in for a well-child visit was ordered the appropriate vaccinations, which included a combination vaccine for DTaP, Hib, and IPV. After administering the shots to the patient, the nurse realized she had given the DTaP vaccination alone, instead of the combination vaccine. Thus, the infant had to receive two additional injections.

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Perspectives on Safety

Resident Duty Hours Policy Changes


In Conversation With… Karl Bilimoria, MD, MS

Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University. He is the principal investigator of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial and a Faculty Scholar at the American College of Surgeons. We spoke with him about the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction. Its results informed recent changes to duty hour policies.


ACGME's 2017 Revision of Common Program Requirements

Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD

This piece reviews how changes to the ACGME requirements emphasize patient safety and quality improvement, address physician well-being, strengthen expectations around team-based care, and create flexibility for work hours within the maximum 80-hour workweek.

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Did You Know?

Clinician-provided reason for voiding medication orders.


Popular Content


Emergency diagnosis of cancer and previous general practice consultations: insights from linked patient survey data.

Abel GA, Mendonca SC, McPhail S, Zhou Y, Elliss-Brookes L, Lyratzopoulos G. Br J Gen Pract. 2017;67:e377-e387.


Why patient safety is such a tough nut to crack.

Leistikow IP, Kalkman CJ, Bruijn H. BMJ. 2011;342:d3447.


Evaluation and certification of computerized physician order entry systems.

Classen D, Avery AJ, Bates DW. J Am Med Inform Assoc. 2007;14:48-55.


It's time to say sorry.

Coombes R. BMJ Podcast. June 1, 2012.


Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.