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05/06/09  
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Journal Articles

Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions.  
Payette M, Chatterjee A, Weeks WB. Am J Surg. 2009 Apr 15; [Epub ahead of print].   

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.
Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009 Apr 2; [Epub ahead of print].

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.
Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.  

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.
O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease.
Murray MD, Ritchey ME, Wu J, Tu W. Arch Intern Med. 2009;169:757-763.

Improved operating room teamwork via SAFETY prep: a rural community hospital's experience.
Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. World J Surg. 2009 Apr 7; [Epub ahead of print].

Hospital complications: linking payment reduction to preventability.
Averill RF, Hughes JS, Goldfield NI, McCullough EC. Jt Comm J Qual Patient Saf. 2009;35:283-285.

Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence.
Masica AL, Richter KM, Convery P, Haydar Z. Proc (Bayl Univ Med Cent). 2009;22:103-111. 

Newspapers/Magazine Articles

Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter.
ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2.

Web Resources

Getting Safer Care.
Agency for Healthcare Research and Quality.

Patient Safety Toolkits & E-learning Packages.
National Patient Safety Agency.

Press Releases/Announcements

Call for participants: AHRQ QI validation pilot phase II.
Agency for Healthcare Research and Quality. April 2009.

2009 Leadership Standards and Patient Safety.
Joint Commission. May 19, 2009; Joint Commission Conference Center, Oakbrook Terrace, IL.

AHRQ's 2009 Annual Conference—Research to Reform: Achieving Health System Change.
Agency for Healthcare Research and Quality. September 13–16, 2009; North Bethesda Marriott, Bethesda, MD.



Primers
Medication Reconciliation, Patient Disclosure, Never Events, Rapid Response Systems, More...
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Safety Target
Medication errors, Diagnostic errors, Nosocomial infections, Post-operative surgical complications, More...

Approach to Improving Safety
Human factors engineering, Error reporting, Teamwork training, Culture of safety, Nurse staffing ratios, Regulation, More...

Error Types
Cognitive errors ("mistakes"), Non-cognitive errors ("slips & lapses"), Latent errors, More...

Clinical Area
Anesthesiology, Emergency medicine, Critical care nursing, Community pharmacy, More...

Target Audience
Physicians, Nurses, Risk managers, Educators, Policymakers, More...

Setting of Care
Intensive care units, Operating room, Children's hospitals, Ambulatory clinic or office, Residential facilities, More...


View ClassicsPatient Safety

Did You Know? View All DYKs

Most ED cases referred to a physician review committe in an urban hospital ED involved three or more contributing factors.
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