Scanning the Headlines: Patient Safety (Archive) 2013-2012

Updated on July 10, 2015

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Links to full-text articles are provided where available.
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Howell, A.  Reducing the burden of surgical harm:  A systematic review of the interventions used to reduce adverse events in surgery.  Annals of Surgery.  Dec. 23, 2013.

Improvements needed in processes used to address providers' actions that contribute to adverse events.  Washington:  United States Government Accountability Office, Dec. 2013.

Aronhalt, K.C., McManus, J., and others.  Patient and environmental service employee satisfaction of using germicidal bleach wipes for patient room cleaning.  Journal for Healthcare Quality;35(6):30-36, Nov.-Dec. 2013. 

Mandavia, R., Yassin, G., and others.  Completing the audit cycle: the impact of an electronic reporting system on the feedback loop in surgical specialties.  Journal for Healthcare Quality;35(6):16-23, Nov.-Dec. 2013. 

Perlin, J.B., Septimus, E.J., and others.  Developing a program to increase seasonal influenza vaccination of healthcare workers: lessons from a system of community hospitals.  Journal for Healthcare Quality;35(6):5-15, Nov.-Dec. 2013. 

Montagnolo, A.J.  New pitfalls in patient safety.  Trustee;66(10):25-26, Nov.-Dec. 2013.

Steyrer, J., Schifflinger, M., and others.  Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors, a study of intensive care units.  Health Care Management Review;38(4):306-316, Oct.-Dec. 2013.

Using good design to eliminate medical errors.  Jaffe E. Fast Company. Nov. 11, 2013.

Lee, J.  Watching out for the youngest patients: providers working on ways to make treatment safer.  Modern Healthcare;43(44):16-18, Nov. 4, 2013. 

Roy, C.L., Rothschild, J.M., and others.  An initiative to improve the management of clinically significant test results in a large health care network.  The Joint Commission Journal on Quality and Patient Safety;39(11):517-527, Nov. 2013

Comprehensive Unit-based Safety Program (CUSP): Patient and Family Engagement Module. Agency for Healthcare Research and Quality, Nov. 2013. 

Sentinel event alert issue 51:  Preventing unintended retained foreign objects.  Washington:  The Joint Commision.  Oct. 17, 2013.

Butcher, L.  Progress, but still a long way to go: researchers see promise in safety measures, but gains uneven.  Modern Healthcare;43(41):30-31, Oct. 14, 2013. 

Malone, E.B.  Reducing medication errors: new FGI requirements on medication safety zones.  Inside ASHE:18-20, Fall 2013.

Birkmeyer, J., and others.  Surgical skill and complication rates after bariatric surgery.  New England Journal of Medicine.  369:1434-1422, Oct. 10, 2013.

Commins, J.  How one rural hospital prevents patient falls.  HealthLeaders Media.  Oct. 2, 2013.   

Chesley B. “Sully” Sullenberger: making safety a core business function.  HFM. Healthcare Financial Management;67(10):50-54, Oct. 2013. 

Weiss, Ph.D., A. and Elixhauser, Ph.D., A.  Characteristics of adverse drug events originating during the hospital stay, 2011 Statistical Brief #164.  Rockville, MD:  Agency for Healthcare Research and Quality, Oct. 2013.

Judson, T.J., Howell, M.D., and others.  Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.  The Joint Commission Journal on Quality and Patient Safety;39(10):468-474, Oct. 2013. 

Jweinat, J., Morris, V., and others.  The Safe Patient Flow Initiative: a collaborative quality improvement journey at Yale-New Haven Hospital.  The Joint Commission Journal on Quality and Patient Safety;39(10):447-459, Oct. 2013. 

Marks, C.M., Kasda, E., and others.  “That was a close call”: endorsing a broad definition of near misses in health care.  The Joint Commission Journal on Quality and Patient Safety;39(10):475-479, Oct. 2013. 

Sloan, T.  Engineering a fail-safe health system: Memorial Hermann wants to eliminate health care errors (really).  H&HN. Hospitals & Health Networks;87(10):34-36, 38, Oct. 2013. 

Younan, L.A., and Fralic, M.F.  Using “best-fit” interventions to improve the nursing intershift handoff process at a medical center in Lebanon.  The Joint Commission Journal on Quality and Patient Safety;39(10):460-467, Oct. 2013. 

Singh H., ed. Diagnostic Error in Medicine [special issue]. BMJ Quality and Safety 22(suppl 2):ii1-ii72, Oct. 2013.

Weiss, A., and Elixhauser, A. Characteristics of adverse drug events originating during the hospital stay, 2011.  HCUP Statistical Brief [Agency for Healthcare Research and Quality] no. 164, Oct. 2013.

O'Hara J., and Isden R. Identifying Risks and Monitoring Safety: the Role of Patients and Citizens. London, UK: Health Foundation; October 2013.

Fakih, M., and others.  Implementing a national program to reduce catheter-associated urinary tract infection:  A quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.  Infection Control and Hospital Epidemiology.  34(10):1048-1054, Oct. 2013.

Case study: compassion fatigue among emergency department staff: a patient safety consideration.  Urgent Matters E-Newsletter.  10(3) Fall 2013.

Pingleton, S.K., Carlton, E., and others.  Reduction of venous thromboembolism (VTE) in hospitalized patients: aligning continuing education with interprofessional team-based quality improvement in an academic medical center.  Academic Medicine;88(10):1454-1459, Oct. 2013. 

Edwards, M.T.  A longitudinal study of clinical peer review’s impact on quality and safety in U.S. hospitals.  Journal of Healthcare Management;58(5):369-385, Sept.-Oct. 2013.

Hong, A.L., Sawyer, M.D., and others.  Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.  Journal for Healthcare Quality;35(5):78-87, Sept.-Oct. 2013. 

Perla, J., Hohmann, S., and Annis, K.  Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization.  Journal for Healthcare Quality. 35(5):20-31, Sept.-Oct. 2013.;jsessionid=0AB7E893F8CE7735B6B5C5FB1C3A16FB.f01t01

Kieke, R.  Study examines top priorities of hospital c-suite executives and risk managers.  Journal of Health Care Compliance.  15(5):41-42, Sept.-Oct. 2013. 

Cannavale, A., Santoni, M., and others.  Risk management in radiology, Radiology Management;35(5):14-19, Sept./Oct. 2013.

Identifying hospital wide harm a set of Icd-9-cm coded conditions associated with increased cost, length of stay, and risk of mortality.  American Journal of Medical Quality.  Sept. 30, 2013.

Embedding safety into culture. Community hospital strives to reduce infections and prevent patient harm.  Hospitals & Health Networks.  Sept. 23, 2013.

Allen, M.  How many die from medical mistakes in U.S. hospitals.  ProPublica.  Sept. 19, 2013.

Antibiotic – resistant bugs have become a common cause of death, says first report of its kind.  Washington Post.  Sept. 16, 2013.

N.H. neuro patients potentially exposed to fatal disease.  Outpatient Surgery News.  Sept. 5, 2013.

Kalisch, B.  Patient – reported missed nursing care correlated with adverse events.  American Journal of Medical Quality.  Sept. 4, 2013.

Whole patient measure of safety: using administrative data to assess the probability of highly undesirable events during hospitalization.  National Association for Healthcare Quality.  Sept. 4, 2013.;jsessionid=1629FCE4412BFC9950D324BD368A155F.f03t04

Clark, C.  Delivering safety over convenience.  HealthLeaders;16(7):66-69, Sept. 2013. 

Barbieri, J.S., Fuchs, B.D., and others.  The mortality review committee: a novel and scalable approach to reducing inpatient mortality.  The Joint Commission Journal on Quality and Patient Safety;39(9):387-395, Sept. 2013.

 Bergquist-Beringer, S., Dong, L, and others.  Pressure ulcers and prevention among acute care hospitals in the United States.  The Joint Commission Journal on Quality and Patient Safety;39(9):404-414, Sept. 2013. 

Paez, K., Roper, R.A., and Andrews, R.M.  Health information technology and hospital patient safety: a conceptual model to guide research.  The Joint Commission Journal on Quality and Patient Safety;39(9):415-425, Sept. 2013.

Universal ICU Decolonization:  An Enhanced Protocol.  Rockville, MD:  Agency for Healthcare Research and Quality, Sept. 2013.

A steep price to pay: fatigue compromises staff and patient safety.  OR Manager;29(9):11-13, Sept. 2013.

James, J.  A new, evidence-based estimate of patient harms associated with hospital care.  Journal of Patient Safety.  9(3) P-122-128. Sept. 2013.,_Evidence_based_Estimate_of_Patient_Harms.2.aspx#

Rizzo, E.  100 patient safety benchmarks.  Becker’s Clinical Quality & Infection Control;2013(3):1, 7-9, Sept. 2013.

Hoppes, M., and others.  Serious safety events: getting to zero.  Journal of Healthcare Risk Management;32(3):27-45, Q1, 2013. 

McLeod, L.A.  Patient transitions from inpatient to outpatient: where are the risks? Can we address them?  Journal of Healthcare Risk Management;32(3):13-19, Q1, 2013. 

Sheppard, F., Williams, M., and Klein, V.R.  TeamSTEPPS and patient safety in healthcare.  Journal of Healthcare Risk Management;32(3):5-10, Q1, 2013. 

Sokol, P.E., and Neerukonda, K.V.  Safety risks in the ambulatory setting.  Journal of Healthcare Risk Management;32(3):21-25, Q1, 2013. 

Clark, C.  Physician’s diagnostic overconfidence may be harming patients.  HealthLeaders Media.  Aug. 27, 2013.

Eisler, P., and Hansen, B.  Dangerous doctors allowed to keep practicing.  USA Today.  Aug. 20, 2013.

Zwaan, L., Schiff, G., and Singh, H.  Advancing the research agenda for diagnostic error reduction.  BMJ Quality & Safety.  Aug. 13, 2013.

Preventing wrong site surgery. Pennsylvania Patient Safety Authority, accessed Aug. 12, 2013.

Rizzo E. 100 patient safety benchmarks. Becker’s Hospital Review, Aug. 12, 2013.

Newman-Toker, D., McDonald, K., and Meltzer, D.  How much diagnostic safety can we afford, and how should we decide?  BMJ Quality & Safety. Aug. 8, 2013.

Taylor, A.M., Chuo, J., and others.  Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.  The Joint Commission Journal on Quality and Patient Safety;39(8):396-403, Aug. 2013. 

Kozhimannil, K.B., Sommerness, S.A., and others.  A perinatal care quality and safety initiative: are there financial rewards for improved quality?  The Joint Commission Journal on Quality and Patient Safety;39(8):339-348, Aug. 2013.

Rinke, M.L., Bundy, D.G., and others.  Bringing central line-associated bloodstream infection prevention home: CLABSI definitions and prevention policies in home health care agencies.  The Joint Commission Journal on Quality and Patient Safety;39(8):361-370, Aug. 2013. 

Zeis, M.  Assessing and improving quality and safety.  HealthLeaders;16(6):26-28, July-Aug. 2013.

Brown, D.S., and Wolosin, R.  Safety culture relationships with hospital nursing sensitive metrics.  Journal for Healthcare Quality;35(4):61-74, July/Aug. 2013. 

Rodak, S.  Study: adverse event reduction led to greater revenue loss than savings.  Beckershospital Review.  July 31, 2013.

Rodak, S.  Is Hand Hygiene Before Gloving Necessary.  Chicago, IL:  Becker’s Healthcare.  July 31, 2013.

Clark, C.  Medical error cost calculator riles AHA.  HealthLeaders Media.  July 26, 2013.

Forced Air Warming Linked to Orthopedic  Surgery Infection.  Chicago, IL:  Becker’s Healthcare.  July 22, 2013.

Healthcare Facility Preparedness Checklist.  Atlanta, GA:  Centers for Disease Control and Prevention.  July 15, 2013.   Healthcare Facility Preparedness Checklist for MERS-CoV

Healthcare Provider Preparedness Checklist for MERS-CoV.  Atlanta, GA:  Centers for Disease Control and Prevention.  July 15, 2013.  Healthcare Provider Preparedness Checklist for MERS-CoV

James, J.T.  New, evidence - based estimate of patient harms associated with hospital care.  Journal of Patient Safety.  July 15, 2013.

Gawande, A., and Maulik, J.  Improving safety in surgery centers.  Hospitals & Health Networks.  July 12, 2013.

Conn, J.  Targeting adverse events: effort aims to ensure health IT causing no harm.  Modern Healthcare;43(27):10, July 8, 2013. 

Lee, J.  Repositioning reprocessing: hospitals see big potential for savings, but safety remains an issue for some.  Modern Healthcare;43(27):32-33, 35, July 8, 2013.

Barr,P.  Quieting alarms on floor can pay big dividends.  Hospitals & Health Networks.  July 3, 2013.

Health IT and Patient Safety Action and Surveillance Safety Plan - Final Plan and Related Materials.  Office of the National Coordinator for Health Information Technology, July 2, 2013.

Pecci, A.W.  Patient safety: now or pay later.  HealthLeaders Media.  July 2, 2013.

Weiss, A., and others.  Origin of adverse drug events in U.S. hospitals, 2011. HCUP Statistical Brief [Agency for Healthcare Research and Quality] no. 158, July 2013.

Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative.  Rockville, MD: Agency for Healthcare Research and Quality, July 2013. .

‘Just Culture’ encourages error reporting, improves patient safety.  OR Manager;29(7):13-15, July 2013. Eliminating Catheter-Associated Urinary Tract Infections.  Chicago:  Health Research and Educational Trust (HRET), July 2013.

Garrett, P.R., and others.  Developing and implementing a standardized process for global trigger tool application across a large health system.  The Joint Commission Journal of Quality and Patient Safety . 39(7):292-297, July 2013. 

Kaufman, J., and others.  A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.  The Joint Commission Journal of Quality and Patient Safety . 39(7):306-311, July 2013. 

Mermel, L.A., and others.  Reducing Clostridium difficile incidence, colectomies, and mortality in the hospital setting.  The Joint Commission Journal of Quality and Patient Safety . 39(7):298-305, July 2013. 

Team effort identifies opportunities to reduce wait times, improve safety for patients.  ED Management . 25(7):81-83, July 2013. 

Taylor, J.A., and others.  Using inpatient hospital discharge data to monitor patient safety events.  Journal of Healthcare Risk Management . 32(4):26-33, Q2 2013. 

Murphy, K.  How EHR Adoption Impacts Patient Safety in the ED.  Danvers, MA:  EHR Intelligence.  June 25, 2013.

Patient notification toolkit: A guide to assist health departments and healthcare facilities with conducting a patient notification following identification of an infection control lapse or disease transmission. Centers for Disease Control and Prevention, June 6, 2013.

Lee, J.  HAIs on the downswing: progress made, but new strategies may be needed.  Modern Healthcare;43(22):14-15, June 3, 2013.  

Sittig, D.F., and Singh, H.  A red flag-based approach to risk management of EHR-related safety concerns.  Journal of Healthcare Risk Management.  33(2):21-26, Quarter 4, 2013.

 Hagman, J., Oman, K., and others.  Lessons learned from the implementation of a bedside handoff model.  JONA. Journal of Nursing Administration;43(6):315-317, June 2013. 

Volz, T.M., and Swaim, T.J.  Partnering to prevent falls: using a multimodal multidisciplinary team.  JONA. Journal of Nursing Administration;43(6):336-341, June 2013.

Wrong-Patient Medication Errors: An Analysis of Event Reports in Pennsylvania and Strategies for Prevention. Pennsylvania Patient Safety Advisory 10(2):41-9, June 2013.;10%282%29/Pages/41.aspx

Bowman, C., Neeman, N., and Sehgal, N.L.  Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture.  Academic Medicine;88(6):802-810, June 2013. 

Mitchell, E.L., and others.  Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.  Academic Medicine;88(6):824-830, June 2013. 

Pincavage, A.T., and others.  Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.  Academic Medicine;88(6):795-801, June 2013. 

Stroud, L., and others.  Teaching medical error disclosure to physicians-in-training: a scoping review.  Academic Medicine;88(6):884-892, June 2013. 

Butcher, L.  The no-fall zone.  H&HN. Hospitals & Health Networks . 87(6):26-30, June 2013. 

Clark, C.  Making patients happy, even the poorest and the sickest.  HealthLeaders . 16(5):58-60, 62, June 2013.

Halamek, L.P.  Editorial: bringing latent safety threats out into the open.  Joint Commission Journal on Quality and Patient Safety;39(6):267, June 2013. 

Implementing a daily huddle protects patients, avoids delays.  OR Manager;29(6):12-13, June 2013. 

New AORN recommendations focus on infection prevention, patient safety.  OR Manager;29(6):20-23, June 2013. 

Paxton, E.W., and others.  Kaiser Permanente implant registries benefit patient safety, quality improvement, cost-effectiveness.  Joint Commission Journal on Quality and Patient Safety;39(6):253-257, June 2013. 

Risk assessment helps prevent falls in ACS patients.  OR Manager;29(6):26, 28, 30, June 2013. 

Shabot, M.M., and others.  Memorial Hermann: high reliability from board to bedside.  Joint Commission Journal on Quality and Patient Safety;39(6):246-252, June 2013. 

Welch, S.J., and others.  Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.  Joint Commission Journal on Quality and Patient Safety;39(6):279-286, June 2013. 

Wetzel, E.A., and others.  Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.  Joint Commission Journal on Quality and Patient Safety;39(6):268-273, June 2013.

Checklists to Improve Patient Safety.  Chicago:  HRET, June 2013.

Giliotti, R.  Exposing safety: putting patients first in imaging departments.  Radiology Management;35(3):9-10, May-June 2013. 

Federico, F.  The leader’s role in medical device safety.  Healthcare Executive.  28(3):82-85, May-June 2013.

Halbesleben, J.R.B., Rathert, C., and Williams, E.S.  Emotional exhaustion and medication administration work-arounds: the moderating role of nurse satisfaction with medication administration.  Health Care Management Review;38(2):95-104, Apr.-June 2013. 

Patient care primer: adverse events after hospital discharge. Agency for Healthcare Research and Quality, accessed May 30, 2013 at

Pharmacologic and Mechanical Prophylaxis of Venous Thromboembolism Among Special Populations; Research Review - Final. Effective Health Care Program, Agency for Healthcare Research and Quality, May 29, 2013. 

Maat, S.  Doctors increasingly shut out of hospital’s patient experience efforts.  American Medical News.  May 27, 2013.

Administering a saline flush “ site unseen ” can lead to a wrong route error.  Institute for Safe Medication Practices.  May 16, 2013.

Clark, C.  Leapfrog hospital safety scores depressing.  HealthLeaders Media.  May 9, 2013.

Birnback, D.J., and others.  A framework for patient safety: a defense nuclear industry-based high-reliability model.  The Joint Commission Journal on Quality and Patient Safety;39(5):233-240, May 2013. 

Jokela, R.  How these 3 wrong site surgeries could have been prevented.  Outpatient Surgery.  14(5).  May, 2013.

Lindenauer PK. Strengthening the business case for patient safety. AHRQ Web M&M, May 2013.

Block, M., and others.  Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).  The Joint Commission Journal on Quality and Patient Safety;39(5):213-220, May 2013. 

Ching, J.M., and others.  Using lean to improve medication administration safety: in search of the “perfect dose.”  The Joint Commission Journal on Quality and Patient Safety;39(5):195-204, May 2013. 

Higher awareness may lower the odds of retained surgical items.  OR Manager;29(5):18-21, May 2013. 

Escorts essential for ensuring postop patient safety.  OR Manager;29(5):28-30, May 2013.

Merlino, J.I., and Raman, A.  Health care’s service fanatics: how the Cleveland Clinic leaped to the top of patient-satisfaction surveys.  Harvard Business Review.  91(5):108-116, May 2013.

Howard,B.  Lessons from America’s safest hospitals more than 180,000 people die every year from hospital errors. Here’s what the top medical centers are doing to improve your odds.  AARP the Magazine.  Apr./May, 2013.

Grady,D.  Hospitals profit from surgical errors, study finds.  New York Times.  Apr. 16, 2013.

O'Reilly, K.  Top 10 ways to improve patient safety now.  Apr. 15, 2013.

Hicks, L., Taylor, T., and Hunkler, R.  U.S. outpatient antibiotic prescribing, 2010.  New England Journal of Medicine.  358:1461-1462, Apr. 11, 2013.

Kowalczyk, L.  Brigham and Women’s airing medical mistakes hospital reports errors to staff in drive for improvement.  The Boston Globe.  Apr. 9, 2013.

The Joint Commission Sentinel Event AlertIssue 50.  Oakbrook Terrace, IL:  The Joint Commission, Apr. 8, 2013.

Rodak, S.  23 Best practices from some of America’s safest hospitals.  Beckers Hospital Review.  Apr. 4, 2013.

Commins, J. CAH study author defends suprising data.  HealthLeaders Media.  Apr. 3, 2013.

Robeznieks, A.  Reducing risk: structure may lead to safer handoffs.  Modern Healthcare;43(13):8-9, 16, Apr. 1, 2013.

Mathias, J.M.  Team training, checklist equal better outcomes in pilot.  OR Manager;29(4):16-17, Apr. 2013. 

Patterson, P.  A ‘cockpit checklist’ reduces defects in instrument sets.  OR Manager;29(4):8-9, 11, Apr. 2013. 

Patterson, P.  Automating sterile processing for safety, efficiency.  OR Manager;29(4):10-11, Apr. 2013. 

Patterson, P.  Safer surgery: six steps that aim for excellence in sterile processing.  OR Manager;29(4):1, 6-7, Apr. 2013.

Collins, J. F.  Patient safety comes first in journey to automate.  Healthcare Executive.  28(2):88-89, Mar.-Apr. 2013.

Hellwig, B.J.  Quality improvement related to radiation safety of chest radiography in the NICU.  Radiology Management;35(2):18-23, Mar.-Apr. 2013. 

Trbovich, P.L., Cafazzo, J.A., and Easty, A.C.  Implementation and optimization of smart infusion systems: are we reaping the safety benefits?  Journal for Healthcare Quality;35(2):33-40, Mar./Apr. 2013.

May, E.L.  The power of zero: steps toward high reliability healthcare.  Healthcare Executive;28(2):16-18, 20, 22, 24, Mar.-Apr. 2013. 

Nelson, W.A.  Addressing the second victims of medical error.  Healthcare Executive;28(2):56, 58-59, Mar.-Apr. 2013.

Clark, C.  Medical error risk rises under shorter medical intern shifts.  HealthLeaders Media.  Mar. 26, 2013.

Pham, J., Frick, K., and Pronovost, P.  Why don't we know whether care is safe?  American Journal of Medical Quality.  Mar. 24, 2013.

Stempniak, M.  CPOE helps avert medication errors, but adoption lags.  H&HN.  Mar. 22, 2013.

Drawn Curtains, Muted Alarms, and Diverted Attention Lead to Tragedy in the Postanesthesia Care Unit.  Horsham, PA:  Institute for Safe Medication Practices.  Mar. 21, 2013.

Rodak, S.  CMS makes hospital inspection reports availale to public.  Becker's Hospital Review.  Mar. 19, 2013.

A guide for HCAs on safe patient transfers.  Nursing Times.  109(26):1-3, Mar. 7, 2013.

Shekelle, P.  Nurse-patient ratios as a patient safety strategy:  A Systematic Review.  Annals Internal Medicine.  158(5 Part 2):404-409, Mar. 5, 2013.

Sullivan, N., and Schoelles, K.  Preventing in-facility pressure ulcers as a patient safety strategy:  A Systematic Review.  Annals Internal Medicine. 158(5 Part 2):410-416, Mar. 5, 2013.

Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety; special issue. Annals of Internal Medicine.  158(5):Part 2, Mar. 5, 2013.

(2013, Mar.).  Making Health Care Safer II.  Rockville, MD:  Agency for Healthcare Research and Quality.  Retrieved from:

Blackmore, C.C., Bishop, R., and others.  Applying lean methods to improve quality and safety in surgical sterile instrument processing.  The Joint Commission Journal on Quality and Patient Safety;39(3):99-105, Mar. 2013. 

Cairns, L.L., Dudjak, L.A.  Utilizing bedside shift report to improve the effectiveness of shift handoff.  JONA. The Journal of Nursing Administration;43(3):160-171, Mar. 2013.

Gregory, K.D., Korst, L.M., and others.  AHRQ patient safety indicators: time to include hemorrhage and infection during childbirth.  The Joint Commission Journal on Quality and Patient Safety;39(3):114-122, Mar. 2013. 

Sculli, G.L., Fore, A.M., and others.  Nursing crew resource management: a follow-up report from the Veterans Health Administration.  JONA. The Journal of Nursing Administration;43(3):122-126, Mar. 2013.

Taufen, A.  Pain points: solutions for drug-seeking patients.  MGMA Connextion.  13(3):44-45, Mar. 2013. 

Through the Eyes of the Workforce Creating Joy, Meaning, and Safer Health Care.   Boston, MA:  Lucian Leape Institute at the National Patient Safety Foundation.  Mar. 2013.  

Making Health Care Safer II:  An Updated Critical Analysis of the Evidence for Patient Safety Practices (Summary).  Rockville, MD:  Agency for Healthcare Research and Quality.  Mar. 2013.

Making Health Care Safer II:  An Updated Critical Analysis of the Evidence for Patient Safety Practices (Full Report).  Rockville, MD:  Agency for Healthcare Research and Quality.  Mar. 2013.

Shojania, K., and Thomas, E.  Trends in adverse events over time:  why are we not improving?  BMJ Quality and Safety.  22(4):273-277, Feb. 26, 2013.

O'Reilly, K. Ways EHRs can lead to unintended safety problems.  Feb. 25, 2013.{AB0069F9-0216-DD11-8901-0015600F6010}&cm_medium=email

Jones, K., and others.  A theory driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals.  Qualitysafety BMJ.  Feb. 23, 2013.

Bowie, P., Skinner, J., and de Wet, C.  Training health care professionals in root cause analysis:  a cross-sectional study of post-training experiences, benefits and attitudes.  BMC Health Services Research.  Feb. 7, 2013.

Timian, A., and others.  Do patients “like” good care? measuring hospital quality via facebook.  American Journal of Medical Quality.  Feb. 1, 2013.

Dellinger, R., and others.  Surviving sepsis campaign:  International guidelines for management of severe sepsis and septic shock:  2012.  SSC Guidelines.  41(2):1-58, Feb. 2013.

Rodak, S.  How health systems can create a robust, enterprise-wide patient safety program.  Becker’s Clinical Quality & Infection Control;2013(1):12-13, Feb. 2013. 

Rodak, S.  Medical device interoperability presents patient safety challenges, opportunities.  Becker’s Hospital Review;2013(2):19, Feb. 2013. 

10 top patient safety issues for 2013.  Becker’s Clinical Quality & Infection Control;2013(1):1, 7-8, Feb. 2013. 

Guide to Preventing Clostridium difficile Infections.  Washington: Association for Professionals in Infection Control and Epidemiology, Inc. Feb. 2013.

Keers, R., and others.  Prevalence and nature of medication administration errors in health care settings:  A systematic review of direct observational evidence.  Annals of Pharmacotherapy.  47(2):237-256, Feb. 2013.

Lin, D.M., Weeks, K., and others.  Maintaining and sustaining the On the Cusp, Stop BSI Model in Hawaii.  The Joint Commission Journal on Quality and Patient Safety;39(2):51-60, Feb. 2013. 

Lineberry, M., Bryan, E., and others.  Measurement and training of TeamSTEPPS dimensions using the medical team performance assessment tool.  The Joint Commission Journal on Quality and Patient Safety;39(2):89-95, Feb. 2013. 

McMullan, C., Propper, G., and others.  A multidisciplinary approach to reduce central line-associated bloodstream infections.  The Joint Commission Journal on Quality and Patient Safety;39(2):61-69, Feb. 2013. 

Poon, S.J., Zuckerman, S.L., and others.  Methodology and bias in assessing compliance with a surgical safety checklist.  The Joint Commission Journal on Quality and Patient Safety;39(2):77-82, Feb. 2013. 

Reilly, J.B., Marcotte, L.M., and others.  Handoff communication between hospitals and outpatient dialysis units at patient discharge: a qualitative study.  The Joint Commission Journal on Quality and Patient Safety;39(2):70-76, Feb. 2013.

McMillan, A., and others.  Continuity of care between family practice physicians and hospitalist services.  Journal for Healthcare Quality . 35(1):41-49, Jan.-Feb. 2013.

Luther, K.  Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.  Healthcare Executive.  28(1):84-87, Jan./Feb. 2013.

Daly, R.  A satisfactory measure? Studies show focus on keeping patients happy can have unintended costs.  Modern Healthcare;43(1):32-33, Jan. 7, 2013. 

Evans, M., and McKinney, M.  Quality paradox: Medicare rewards for process, patient satisfaction not always linked to better outcomes.  Modern Healthcare;43(1):6-7, 16, Jan. 7, 2013. 

Krumholz, H.  Post-hospital syndrome ----  An acquired, transient condition of generalized risk.  New England Journal of Medicine.  368:100-102, Jan. 10, 2013.

(2013, Jan.).  Preventing Falls in Hospitals.  Rockville, MD:  Agency for Healthcare Research and Quality.  Retrieved from:

Moran, J., and Scanlon, D.  Slow progress on meeting hospital safety standards: learning from The Leapfrog Group’s efforts.  Health Affairs;32(1):27-35, Jan. 2013.

Percarpio, K.B., and Watts, B.V.  A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs Medical Centers.  The Joint Commission Journal on Quality and Patient Safety;39(1):32-37, Jan. 2013.

Jarousse, L.A.  Radiation dose management: a patient safety priority.  H&HN. Hospitals & Health Networks . 87(1):gatefold, Jan. 2013.

Moran, J., and Scanlon, D.  Slow progress on meeting hospital safety standards: learning from the Leapfrog Group’s efforts.  Health Affairs.  32(1):27-35, Jan. 2013. 

Michtalik, H., and others.  Impact of attending physician workload on patient care:  A survey of hospitalists.  JAMA.  173(5):375-377, 2013.

Stobbe, M.  Medication nation:  Study shows antibiotic overuse.  New England Journal of Medicine, 2013.

Eappen, S.,Lane, BH., and Rosenberg,B.  Relationship between occurrence of surgical complications and hospital finances.  JAMA; 309:1599-1606, 2013.

Bradley, S.  Ambulatory Surgical Facilities: Strategies to Integrate Basic Infection Control Concepts into Clinical Practice.  Harrisburg, PA:  Pennsylvania Patient Safety Authority.  2013.

Improving Your Office Testing Process a Toolkit for Rapid Cycle Patient Safety and Quality Improvement.  Rockville, MD:  Agency for Healthcare Research and Quality.  2013.

Infection Prevention for Ambulatory Care Centers During  Disasters.  Washington, DC:  APIC.  2013. 

Preventing Hospital Acquired Venous Thromboembolism a Guide for Effective Quality Improvement.  Rockville, MD:  Agency for Healthcare Research and Quality.  2013.

Gao, T., and Gaunt, M. Breakdowns in the medication reconciliation process. PA-PSRS Patient Safety Advisor. 10:125-136, 2013.

ESA/EBA Patient Safety Task Force. Patient Safety in Anaesthesiology: Patient Safety Starter Kit.  European Society of Anaesthesiology; 2013. 

Working for Quality.  2013 Annual Progress Report to Congress.  Rockville, MD:  Agency for Healthcare Research and Quality.  2013.

Strategy for a National EMS Culture of Safety. Irving, TX: American College of Emergency Physicians; 2013. 

Greenstein, E., and others.  Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.  BMJ Quality and Safety.  Dec. 20, 2012.

Johns Hopkins malpractice study: surgical 'never events' occur at least 4,000 times per year.  Johns Hopkins Medicine Press Release, Dec. 19, 2012.

Boodman, S. Aging doctors face greater scrutiny.  Washington Post.  Dec. 10, 2012.

Beware of malware on medical devices.  ECRI.  24(12):1-3, Dec. 2012.{AB0069F9-0216-DD11-8901-0015600F6010}&cm_medium=email

Agrawal, A.  Counting matters: lessons from the root cause analysis of a retained surgical item.  The Joint Commission Journal on Quality and Patient Safety;38(12):566-574, Dec. 2012.

Akridge, J.  Sticking points: sharp-minded tips for reducing needlesticks.  Healthcare Purchasing News;36(12):18, 20, 22, 24, Dec. 2012.

Goldfield, N., Kelly, W.P., and Patel, K.  Potentially preventable events: an actionable set of measures for linking quality improvement and cost savings.  Quality Management in Health Care;21(4):213-219, Oct.-Dec. 2012.

Rossi, A.P., and others.  Use of computer alerts to prevent the inappropriate use of Metformin in an inpatient setting.  Quality Management in Health Care;21(4):235-239, Oct.-Dec. 2012.

Clark, C.  How hospitals prevent VTE.  HealthLeaders Media.  Nov. 27, 2012.

Mertens, W.C., and others.  Using process elicitation and validation to understand and improve chemotherapy ordering and delivery.  The Joint Commission Journal on Quality and Patient Safety;38(11):497-505, Nov. 2012.

Pines, J.M., and others.  Procedural safety in emergency care: a conceptual model and recommendations.  The Joint Commission Journal on Quality and Patient Safety;38(11):516-526, Nov. 2012.

Siemieniuk, R.A.C., Fonseca, K., and Gill, M.J.  Using root cause analysis and form redesign to reduce incorrect ordering of HIV tests.  The Joint Commission Journal on Quality and Patient Safety;38(11):506-512, Nov. 2012.

Vetter, T.R., Ali, N.M.K., and Boudreaux, A.M.  A case-control study of an intraoperative corneal abrasion prevention program: holding the gains made with a continuous quality improvement effort.  The Joint Commission Journal on Quality and Patient Safety;38(11):490-496, Nov. 2012.

Prevention of Healthcare-Associated InfectionsExecutive Summary.  Rockville, MD:  Agency for Healthcare Research and Quality, Nov. 2012.

Wasvary, R.  CDC recommendations for bed bugs.  FacilityCare;17(6):36-37, Oct./Nov. 2012.

Clark, C.  Mandatory use of CPOE prevents blood clots.  HealthLeaders Media.  Oct. 16, 2012.

Hoppes, M., and others.  Serious Safety Events:  Getting to Zero.  Chicago:  American Society for Healthcare Risk Management (ASHRM), Oct. 15, 2012.

How-to Guide:  Prevent Obstetrical Adverse Events.  Cambridge, MA:  Institute for Healthcare Improvement, Oct. 12, 2012.

Catheter-associated urinary tract infections: education, product and teamwork help Mercy Medical Center reduce CAUTIs.  The Journal of Healthcare Contracting;9(5):44-46, Oct. 2012.

ECRI Institute. Judgment call [handling smartphones and other mobile devices in your hospital]. Health Devices, Oct. 2012.

Pear, R.   New system for patients to report medical mistakes.  New York, NY:  New York Times.  Sept. 22, 2012.

Clark, C.  Blood infections plunge 40% under safety protocol.  HealthLeaders Media.  Sept. 11, 2012.

Christian, G., Classen, D., and Griffin, F.A.  Leadership best practices to prevent hospital-associated infections.  Journal of Patient Safety;8(3):144-148, Sept. 2012.

Gottumukkala, R., and others.  Improving team performance during the preprocedure time-out in pediatric interventional radiology.  The Joint Commission Journal on Quality and Patient Safety;38(9):387-394, Sept. 2012.

Kellett, J.  Editorial: will continuous surveillance monitoring of vital signs provide cheaper, safer, and better hospital care for all?  The Joint Commission Journal on Quality and Patient Safety;38(9):426-427, Sept. 2012.

Lovig, K.O., and others.  Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error?  The Joint Commission Journal on Quality and Patient Safety;38(9):403-407, Sept. 2012.

Mion, L.C., and others.  Is it possible to identify risks for injurious falls in hospitalized patients?  The Joint Commission Journal on Quality and Patient Safety;38(9):408-413, Sept. 2012.

Pernar, L.I.M., and others.  Using an objective structured clinical examination to test adherence to Joint Commission national patient safety goal-associated behaviors.  The Joint Commission Journal on Quality and Patient Safety;38(9):414-418, Sept. 2012.

Peterson, T.H., Teman, S.F., and Connors, R.H.  A safety culture transformation: its effects at a children’s hospital.  Journal of Patient Safety;8(3):125-130, Sept. 2012.

Pyke, J., and others.  Developing a continuous monitoring infrastructure for detection of inpatient deterioration.  The Joint Commission Journal on Quality and Patient Safety;38(9):428-431, Sept. 2012.

Improving Patient Safety Systems for Patients With Limited English Proficency.  A Guide for Hospitals.  Rockville, MD:  Agency for Healthcare Research and Quality, Sept. 2012.

Nurse staffing and patient safety; interview - in conversation with…Jack Needleman, PhD. Perspectives on Safety Safety, Sept. 2012.

Nolte, E., and McKee, C.  In Amenable Mortality—Deaths Avoidable Through Health Care—Progress in the US Lags That of Three European Countries, Health AffairsWeb First, published online Aug. 29, 2012.

Clark, C.  Diagnostic errors found in 1 of 4 ICU patient deaths.  HealthLeaders Media.  Aug. 28, 2012.

Draper, D.  Veterans Health Administration Processes for Responding to Reported Adverse Events.  Washington:  U.S. Government Accountability Office.  Aug. 24, 2012.

Conry, M. and others.   A 10 year (2000-2010) systematic review of interventions to improve quality of care in hospitals.  BMC Health Services Research.  12(275):1472-6963, Aug. 24, 2012

Mace, S.  EMR safety warnings at CA Health System echo Joint Commission's.  HealthLeaders Media.  Aug. 21,2012.

Survey: Nearly One in Three Americans Report Experiencing Medical Mistakes, Either Themselves or Among Family and Friends. Wolters Kluwer press release, Aug. 15, 2012.

Wolters Kluwer Health Quarterly Poll:  Medical Mistakes.  Wolters Kluwer Health.  Aug. 15, 2012.

Chassin, M.  The evolution of patient safety.  H&HN.  Aug. 13, 2012.

Safe use of opioids in hospitals. Joint Commission Sentinel Event Alert. (49):1-5, Aug. 8, 2012.

Terhune C. Patient data outage exposes risks of electronic medical records.  Los Angeles Times. August 3, 2012:B1.,0,5302779.story

Foster, S., and Manser, T.  The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.  Academic Medicine;87(8):1105-1124, Aug. 2012.

The House of Gort [video]. StaleFish Production Company, Aug. 2012.

Shaw, G.  Most adverse events at hospitals still go unreported.  Hospitalist.  Aug. 2012.

Trew, M., Nettleton, S., and Flemons, W.  Harm to Healing - Partnering with Patients Who Have Been Harmed.  Candian:  CPSI ICSP, Aug. 2012.

Cimiotti, J., and others.  Nurse staffing, burnout, and health care-associated infection.  American Journal of Infection Control.  40(6):486-490, Aug. 2012.

Herzer, K.P., and others.  Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and “good catch” awards.  The Joint Commission Journal on Quality and Patient Safety;38(8):339-347, Aug. 2012.

Tietze, M.F., and others.  Deep vein thrombosis/pulmonary embolism: a survey of self-reported prevention practices among hospitals.  Journal for Healthcare Quality;34(4):15-23, July/Aug. 2012. 

Kabcenell, A., and Luther, K.  Creating a culture of excellence.  Healthcare Executive;27(4):68, 70-71, July/Aug. 2012.

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.  Washington:  U.S. Department of Health and Human Services, July 19, 2012. 

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. US Government Accountability Office, July 13, 2012.

PCA Safety Checklist.  Nashville, TN:  Physician-Patient Alliance for Health and Safety. July 2012.

Touchette, D., Stubbings, J., and Schumock, G.  Effective Health Care Program Research Reports.  Improving Medication Safety in High Risk Medicare Beneficiaries Toolkit.  Rockville, MD :  Agency for Healthcare Research and Quality.  July 2012.

Morello, R., and others.  Strategies for improving patient safety culture in hospitals: s systematic review.  BMJ Quality & Safety.  July 2012.

Encinosa, W.E., and Bae, J.  How can we bend the cost curve? Health information technology and its effects on hospital costs, outcomes, and patient safety.  Inquiry;48(4):288-303,Winter 2011/2012.

Minnick, A.F., and others.  Operating room team members’ views of workload, case difficulty, and nonroutine events.  Journal for Healthcare Quality;34(3):16-24, June 2012.

Byrd, J.R., and Singh, L.  Breadth and depth of anesthesia drug shortages increasing: summary of ASA survey.  Newsletter [American Society of Anesthesiologists];76(6):56-75, June 2012.

Curbing OR traffic: finding ways to minimize the flow of personnel.  OR Manager;28(6):1, 9-11, June 2012.

National Voluntary Consensus Standards for Patient Safety Measures: A Consensus Report.  Washington, DC: National Quality Forum; June 2012. 

A cure for the distracted time-out before surgery.  OR Manager;28(6):12-14, June 2012.

Coburn, A., and Gage-Croll, Z.  Improving Hospital Patient Safety Through Teamwork:  The Use of TeamSTEPPS in Critical Access Hospitals.  Policy Brief #21.  Flex Monitoring Team, June 2011.

Welch, J. Alarm fatigue hazards: the sirens are calling.  Patient Safety and Quality Healthcare.  9:26-29,32-33, May/June 2012.

Hofmann, P. The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations?  Healthcare Executive.  27:64,66-67, May-June 2012.

Taylor, M.  Hospital engagement networks:  10 big goals in 2 short years.  H&HN.  May 5, 2012.

Patient Safety and Satisfaction: The State of American Hospitals. HealthGrades, May 2012.

Sorra, J., and others. 2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture.  Rockville, MD: Agency for Healthcare Research and Quality, May 2012.

Do no harm, Jess story [video]., Apr. 27, 2012.

Yu, H., and others.  Multiple patient safety events within a single hospitalization:  A national profile in US hospitals.  American Journal of Medical Quality.  Apr. 2012.

Akridge, J.  Word of mouth: oral care basics prevent pneumonia.  Healthcare Purchasing News;36(4):16-19, Apr. 2012.

Bandari, J., and others.  Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.  The Joint Commission Journal on Quality and Patient Safety;38(4):154-160, Apr. 2012. 

Smith, M.  Count sheets: where do we put them?  Healthcare Purchasing News;36(4):50-51, Apr. 2012.

May, E.L.  The pursuit of perfection: hospitals take heightened actions to reduce adverse events.  Healthcare Executive;27(2):26-28, 30-33, Mar.-Apr. 2012. 

Leach, L.S., and others.  Improving patient safety to reduce preventable deaths:  The case of a California safety net hospital.  Journal for Healthcare Quality;34(2):64-76, Mar./Apr. 2012.

Cantrell, S.  Innovative medical devices improve patient safety.  Healthcare Purchasing News. (3):22, 24, 26, Mar. 2012.

Mathias, J.M.  Capnography: new standard of care for sedation?  OR Manager.  (3):17-20, Mar. 2012

Denham, C.R., and others.  An NTSB for health care: learning from innovation: debate and innovate or capitulate.  Journal of Patient Safety;8(1):3-14, Mar. 2012.

Davis, R.E., and others.  An examination of opportunities for the active patient in improving patient safety.  Journal of Patient Safety;8(1):36-43, Mar. 2012.

Menta, S.P.  Cautery fires in the operating room.  American Society of Anesthesiologists Newsletter;76(2):16-18, Feb. 2012.

Sirriyeh, R., and others.  Safety subcultures in health-care organizations and managing medical error.  Health Services Management Research;25(1):16-23, Feb. 2012.

Woodrow, C., and Guest, D.E.  Public violence, staff harassment and  the wellbeing of nursing staff: an analysis of national survey data.  Health Services Management Research;25(1):24-30, Feb. 2012.

Hussain, A., and others.  Strategies for dealing with future shortages in the nursing workforce: a review.  Health Services Management Research;25(1):41-47, Feb. 2012. 

Downey, J.R., and others.  Is patient safety improving? National trends in patient safety indicators: 1998-2007.  Health Services Research;47(1, Part 2):414-430, Feb. 2012.

McKinney, M.  Putting it to the test.  Modern Healthcare.  42(7):12, Feb. 13, 2012.

Clinical pharmacists with EM training slash medication errors, help to optimize therapies in the ED.  ED Management.  24(2):13-16, Feb. 2012.

Gray, J., and Raxmus, I.  Improving venous thromboembolism prevention processes and outcomes at a community hospital.  The Joint Commission Journal on Quality and Patient Safety.  38(2):61-66, Feb. 2012.

Kliger, J., and others.  Spreading a medication administration intervention organizationwide in six hospitals.  The Joint Commission Journal on Quality and Patient Safety. 38(2):51-60, Feb. 2012.

Lin, C.J., Nowalk, M.P., and Zimmerman, R.K.  Estimated costs associated with improving influenza vaccination for health care personnel in a multihospital system.  The Joint Commission Journal on Quality and Patient Safety.  38(2):67-72, Feb. 2012.

Wagner, B., and others.  Comprehensive perinatal safety initiative to reduce adverse obstetric events.  Journal for Healthcare Quality;34(1):6-15, Jan.-Feb. 2012. 

Sun, L.  Hospital fountain linked to legionnaires' outbreak.  Washington Post.  Jan. 10, 2012.

Infection risks from reusable devices are low but present, says FDA.  Outpatient Surgery Magazines.  Jan. 3, 2012.

Cantrell, S.  Keeping IV infections out of site.  Healthcare Purchasing News.  36(1):16, 18, 20, Jan. 2012.

Wakefield, D.S., and others.  A review of verbal order policies in acute care hospitals.  The Joint Commission Journal on Quality and Patient Safety.  38(1):24-33, Jan. 2012. 

Joseph, A., Talyor, E., and Quan, X.  Designing for patient safety: findings from a national seminar.  Healthcare Design;12(1):20, 22-25, Jan. 2012.

McLaughlin, S.B.  Standard issues: avoiding frequent Joint Commission deficiencies.  Health Facilities Management.  25(1):37-40, Jan. 2012.

Esparza, S.J., and others.  Nurse staffing and skill mix patterns: are there differences in outcomes?  Journal of Healthcare Risk Assessment;31(3):14-23, First Quarter 2012.

Fernandes, O., and Shojania, G.  Medication reconciliation in the hospital:  What, why, where, when, who and how?  Healthcare Quarterly.  15(Special issue):42-49, 2012.

Insidious Intimidation, a Real Threat to Patient Safety, 2012.

Hayes, C.  Surgical safety checklist:  Improved patient safety through effective teamwork.  Healthcare Quarterly.  15(Special issue):57-62, 2012.

Stevenson, L., and others.  Safety in home care:  Thinking outside the hospital box. Healthcare Quarterly.  15(Special issue):68-72, 2012.

Dhalla, I., and others.  Toward safer transitions:  How can we reduce post-discharge adverse events?  Healthcare Quarterly.  15(Special issue):63-67, 2012.

O'Connor, P., and others.  Redesigning the workplace for 21st century healthcare.  Healthcare Quarterly.  15(Special issue):30-35, 2012.

Lingard, L.  Productive complications:  Emergent ideas in team communication and patient safety.  Healthcare Quarterly.  15(Special issue):18-23, 2012.

American Hospital Quality Outcomes 2013:  Healthgrades Report to the Nation.  Healthgrades, 2012.

Designing for Patient Safety:  Developing Methods to Integrate Patient Safety Concerns in the Design Process.  Concord, CA:  The Center for Health Design, 2012.

Hospital Survey on Patient Safety Culture:  2012 User Comparative Database Report.  Rockville, MD:  Agency for Healthcare Research and Quality, 2012.

Chatman, I.  Pressure Ulcer Prevention Toolkit.  OakBrook Terrace, IL:  Joint Commission Resources, 2012.  (WR 598 P935u 2012).


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