Scanning the Headlines: Patient Safety

                                                                          

Updated on March 18, 2013

Click here for Patient Safety Archive Bibliography

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Links to full-text articles are provided where available.
For information on obtaining print copies of articles, please call the AHA Resource Center at (312) 422-2050.

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.  http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetysum.pdf

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.  http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyII-full.pdf

O'Reilly, K. Ways EHRs can lead to unintended safety problems.  amednews.com.  Feb. 25, 2013.  http://www.ama-assn.org/amednews/2013/02/25/prsa0225.htm?cm_mid=2236634&cm_crmid={AB0069F9-0216-DD11-8901-0015600F6010}&cm_medium=email

Guide to Preventing Clostridium difficile Infections.  Washington: Association for Professionals in Infection Control and Epidemiology, Inc. Feb. 2013.  http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

Greenstein, E., and others.  Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.  BMJ Quality and Safety.  Dec. 20, 2012.  http://qualitysafety.bmj.com/content/early/2012/12/19/bmjqs-2012-001138

Boodman, S. Aging doctors face greater scrutiny.  Washington Post.  Dec. 10, 2012.  http://www.kaiserhealthnews.org/Stories/2012/December/11/aging-doctors-face-greater-scrutiny.aspx

Beware of malware on medical devices.  ECRI.  24(12):1-3, Dec. 2012.  https://www.ecri.org/EmailResources/Emerging_Technology_Brief/2013/Emerging_Tech_Brief_February_2013.pdf?cm_mid=2126934&cm_crmid={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.  http://www.healthleadersmedia.com/content/PHY-286839/How-Hospitals-Prevent-VTE

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.

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.  http://www.healthleadersmedia.com/content/TEC-285459/Mandatory-Use-of-CPOE-Prevents-Blood-Clots##

Hoppes, M., and others.  Serious Safety Events:  Getting to Zero.  Chicago:  American Society for Healthcare Risk Management (ASHRM), Oct. 15, 2012.  http://www.ashrm.org/ashrm/resources/SSEs/SSE%20White%20Pape_10-5-12_FINAL.pdf

How-to Guide:  Prevent Obstetrical Adverse Events.  Cambridge, MA:  Institute for Healthcare Improvement, Oct. 12, 2012.  http://www.ihi.org/knowledge/pages/tools/howtoguidepreventobstetricaladverseevents.aspx

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.

Pear, R.   New system for patients to report medical mistakes.  New York, NY:  New York Times.  Sept. 22, 2012.  http://www.nytimes.com/2012/09/23/health/new-system-for-patients-to-report-medical-mistakes.html?_r=2&emc=tnt&tntemail0=y

Clark, C.  Blood infections plunge 40% under safety protocol.  HealthLeaders Media.  Sept. 11, 2012.  http://www.healthleadersmedia.com/page-1/QUA-284289/Blood-Infections-Plunge-40-Under-Safety-Protocol

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.  http://www.ahrq.gov/populations/lepguide/

Nurse staffing and patient safety; interview - in conversation with…Jack Needleman, PhD. Perspectives on Safety Safety, Sept. 2012. http://www.webmm.ahrq.gov/perspective.aspx?perspectiveId=127

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.  http://www.commonwealthfund.org/Publications/In-the-Literature/2012/Aug/Variations-Amenable-Mortality.aspx?omnicid=20

Clark, C.  Diagnostic errors found in 1 of 4 ICU patient deaths.  HealthLeaders Media.  Aug. 28, 2012.  http://www.healthleadersmedia.com/content/PHY-283808/Diagnostic-Errors-Found-in-1-of-4-ICU-Patient-Deaths##

Draper, D.  Veterans Health Administration Processes for Responding to Reported Adverse Events.  Washington:  U.S. Government Accountability Office.  Aug. 24, 2012.   http://www.gao.gov/products/GAO-12-827R

Mace, S.  EMR safety warnings at CA Health System echo Joint Commission's.  HealthLeaders Media.  Aug. 21,2012.  http://www.healthleadersmedia.com/content/TEC-283622/EMR-Safety-Warnings-at-CA-Health-System-Echo-Joint-Commissions##

Survey: Nearly One in Three Americans Report Experiencing Medical Mistakes, Either Themselves or Among Family and Friends. Wolters Kluwer press release, Aug. 15, 2012. http://www.wolterskluwer.com/Press/Latest-News/2012/Pages/pr15Aug2012.aspx

Wolters Kluwer Health Quarterly Poll:  Medical Mistakes.  Wolters Kluwer Health.  Aug. 15, 2012.  http://www.wolterskluwerhealth.com/News/Documents/White%20Papers/Wolters%20Kluwer%20Health%20Medical%20Mistakes%20Survey%20Executive%20Summary.pdf

Chassin, M.  The evolution of patient safety.  H&HN.  Aug. 13, 2012. http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8150009407

Safe use of opioids in hospitals. Joint Commission Sentinel Event Alert. (49):1-5, Aug. 8, 2012.  http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf

Terhune C. Patient data outage exposes risks of electronic medical records.  Los Angeles Times. August 3, 2012:B1.  http://www.latimes.com/business/la-fi-hospital-data-outage-20120803,0,5302779.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.  http://vimeo.com/46597387

Shaw, G.  Most adverse events at hospitals still go unreported.  Hospitalist.  Aug. 2012.  http://www.the-hospitalist.org/details/article/2360341/Most_Adverse_Events_at_Hospitals_Still_Go_Unreported.html

Trew, M., Nettleton, S., and Flemons, W.  Harm to Healing - Partnering with Patients Who Have Been Harmed.  Candian:  CPSI ICSP, Aug. 2012.  http://www.patientsafetyinstitute.ca/English/research/commissionedResearch/HarmtoHealing/Documents/Harm%20to%20Healing.pdf

Cimiotti, J., and others.  Nurse staffing, burnout, and health care-associated infection.  American Journal of Infection Control.  40(6):486-490, Aug. 2012.  http://www.ajicjournal.org/article/S0196-6553%2812%2900709-2/fulltext

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.  http://www.oig.hhs.gov/oei/reports/oei-06-09-00092.asp 

Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. US Government Accountability Office, July 13, 2012.  http://www.gao.gov/products/GAO-12-712

PCA Safety Checklist.  Nashville, TN:  Physician-Patient Alliance for Health and Safety. July 2012.  http://ppahs.files.wordpress.com/2012/07/pca-safety-checklist3.pdf

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.  http://effectivehealthcare.ahrq.gov/ehc/products/33/1186/DEcIDE38_Toolkit_20120711.pdf

Morello, R., and others.  Strategies for improving patient safety culture in hospitals: s systematic review.  BMJ Quality & Safety.  July 2012.  http://qualitysafety.bmj.com/content/early/2012/07/30/bmjqs-2011-000582

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.  http://www.qualityforum.org/Publications/2012/06/Patient_Safety_Measures_Final_Report.aspx

 

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.  http://flexmonitoring.org/documents/PolicyBrief21_TeamSTEPPS.pdf

Welch, J. Alarm fatigue hazards: the sirens are calling.  Patient Safety and Quality Healthcare.  9:26-29,32-33, May/June 2012.
http://www.psqh.com/mayjune-2012/1291-alarm-fatigue-hazards-the-sirens-are-calling.html

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.  http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/05MAY2012/0512HHN_FEA_qualitymatters&domain=HHNMAG

Patient Safety and Satisfaction: The State of American Hospitals. HealthGrades, May 2012.  https://www.cpmhealthgrades.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf

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. http://www.ahrq.gov/qual/mosurvey12/index.html

Do no harm, Jess story [video]. YouTube.com, Apr. 27, 2012.  http://www.youtube.com/watch?v=t6mr3gxXx64&feature=youtu.be

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.  http://ajm.sagepub.com/content/early/2012/04/06/1062860612441052.abstract

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.  http://www.hpnonline.com/inside/2012-03/1203-IP-Safety.html

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.  http://viewer.zmags.com/publication/1da72863#/1da72863/18

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.  http://www.washingtonpost.com/national/health-science/hospital-fountain-linked-to-legionnaires-outbreak/2012/01/10/gIQAyLwEpP_story.html

Infection risks from reusable devices are low but present, says FDA.  Outpatient Surgery Magazines.  Jan. 3, 2012.  http://www.outpatientsurgery.net/news/2012/01/2-Infection-Risks-From-Reusable-Devices-Are-Low-But-Present-Says-FDA

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.  http://www.hfmmagazine.com/hfmmagazine_app/jsp/articledisplay.jsp?domain=HFMMAGAZINE&dcrpath=HFMMAGAZINE/Article/data/01JAN2012/0112HFM_FEA_CodesStandards

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.  http://www.beckershospitalreview.com/quality/51-hospitals-with-the-lowest-30-day-readmission-rates-from-heart-failure.html

Insidious Intimidation, a Real Threat to Patient Safety, 2012.  http://www.nxtbook.com/nxtbooks/naylor/AHHQ0310/index.php

Hayes, C.  Surgical safety checklist:  Improved patient safety through effective teamwork.  Healthcare Quarterly.  15(Special issue):57-62, 2012.  http://www.longwoods.com/content/22840

Stevenson, L., and others.  Safety in home care:  Thinking outside the hospital box. Healthcare Quarterly.  15(Special issue):68-72, 2012.  http://www.longwoods.com/content/22838

Dhalla, I., and others.  Toward safer transitions:  How can we reduce post-discharge adverse events?  Healthcare Quarterly.  15(Special issue):63-67, 2012.  http://www.longwoods.com/content/22839

O'Connor, P., and others.  Redesigning the workplace for 21st century healthcare.  Healthcare Quarterly.  15(Special issue):30-35, 2012.  http://www.longwoods.com/content/22844

Lingard, L.  Productive complications:  Emergent ideas in team communication and patient safety.  Healthcare Quarterly.  15(Special issue):18-23, 2012.  http://www.longwoods.com/content/22846

American Hospital Quality Outcomes 2013:  Healthgrades Report to the Nation.  Healthgrades, 2012.  http://c773731.r31.cf2.rackcdn.com/d0/ce/09b1df7b4fb4960b69dcb50313e3/Healthgrades%20American%20Hospital%20Quality%20Report%202013.pdf

Designing for Patient Safety:  Developing Methods to Integrate Patient Safety Concerns in the Design Process.  Concord, CA:  The Center for Health Design, 2012.  http://www.healthdesign.org/sites/default/files/chd416_ahrqreport_final.pdf

Hospital Survey on Patient Safety Culture:  2012 User Comparative Database Report.  Rockville, MD:  Agency for Healthcare Research and Quality, 2012.  http://www.ahrq.gov/qual/hospsurvey12/hosp12summ.htm

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