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Journal Article

Evaluating serial strategies for preventing wrong-patient orders in the NICU.

Adelman JS, Aschner JL, Schechter CB, et al. Pediatrics. 2017;139:e20162863.

Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.

Aiken LH, Sloane D, Griffiths P, et al; RN4CAST Consortium. BMJ Qual Saf. 2017;26:559-568.

Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two Canadian adverse event studies.

Sears NA, Blais R, Spinks M, Paré M, Baker GR. BMC Health Serv Res. 2017;17:400.

Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis.

Luxenberg A, Chan B, Khanna R, Sarkar U. JAMA Intern Med. 2017 Jun 19; [Epub ahead of print].

Clinical outcomes associated with medication regimen complexity in older people: a systematic review.

Wimmer BC, Cross AJ, Jokanovic N, et al. J Am Geriatr Soc. 2017;65:747-753.

Microanalysis of video from the operating room: an underused approach to patient safety research.

Bezemer J, Cope A, Korkiakangas T, et al. BMJ Qual Saf. 2017;26:583-587.

What we know about designing an effective improvement intervention (but too often fail to put into practice).

Marshall M, de Silva D, Cruickshank L, Shand J, Wei L, Anderson J. BMJ Qual Saf. 2017;26:578-582.

The second victim: a review.

Coughlan B, Powell D, Higgins MF. Eur J Obstet Gynecol Reprod Biol. 2017;213:11-16.

Changing the narratives for patient safety.

Pronovost PJ, Sutcliffe KM, Basu L, Dixon-Woods M. Bull World Health Organ. 2017;95:478-480.

Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture.

Davies J, Pucher PH, Ibrahim H, Stubbs B. J Surg Res. 2017;212:222-228.

A piece of my mind. Speak up.

Merrill DG. JAMA. 2017;317:2373-2374.

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.

Special or Theme Issue

The 2016 John M. Eisenberg Patient Safety and Quality Awards.

Jt Comm J Qual Patient Saf. 2017;43:315-337.

Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Rude providers jeopardize patient safety. So stop it.

Thew J. HealthLeaders Media. June 14, 2017.

Meeting/Conference

Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation.

van Pelt M, Weinger MB. Anesth Analg. 2017 Jun 9; [Epub ahead of print].

IHI/NPSF Webcast: The Business Case for Patient Safety.

IHI/NPSF Patient Safety Coalition, Healthcare Financial Management Association. July 25, 2017; 1:00–2:00 PM (Eastern).

Also of Note

TeamStepps Advanced Course.

Agency for Healthcare Research and Quality, Health Research & Educational Trust. August 1, August 11, and August 25, 2017.

Improving Diagnosis in Health Care: An Implementation Workshop.

The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.

WebM&M Cases

The Perils of Contrast Media

  • Spotlight Case
  • CME/CEU

Commentary by Umar Sadat, MD, PhD, and Richard Solomon, MD

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

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Chest Tube Complications

Commentary by Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Diagnostic Overshadowing Dangers

Commentary by Maria C. Raven, MD, MPH, MSc

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

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Perspectives on Safety

The Weekend Effect

Interview

In Conversation With… Paul Aylin, MBChB

Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.

Perspective

The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?

Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS

This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.

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