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Journal Article

Readmission rates after passage of the Hospital Readmissions Reduction Program: a pre–post analysis.

Wasfy JH, Zigler CM, Choirat C, Wang Y, Dominici F, Yeh RW. Ann Intern Med. 2016 Dec 27; [Epub ahead of print].

Safety of overlapping surgery at a high-volume referral center.

Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2016 Dec 5; [Epub ahead of print].

Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures.

Weingart SN, Stoffel EM, Chung DC, et al. Jt Comm J Qual Patient Saf. 2017;43:32-40.

A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study.

Snowden JM, Kozhimannil KB, Muoto I, Caughey AB, McConnell KJ. BMJ Qual Saf. 2017;26:e1.

Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions.

Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.

Ensuring staff safety when treating potentially violent patients.

Roca RP, Charen B, Boronow J. JAMA. 2016;316:2669-2670.

Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review.

Kim MO, Coiera E, Magrabi F. J Am Med Inform Assoc. 2016 Dec 23; [Epub ahead of print].

War games and diagnostic errors.

Vaughn VM, Chopra V, Howell JD. BMJ. 2016;355:i6342.

Processes for identifying and reviewing adverse events and near misses at an academic medical center.

Martinez W, Soleymani Lehmann L, Hu YY, Desai SP, Shapiro J. Jt Comm J Qual Patient Saf. 2017;43:5-15.

Changes in physician practice patterns after implementation of a communication-and-resolution program.

Helmchen LA, Lambert BL, McDonald TB. Health Serv Res. 2016;51(suppl 3):2516-2536.

Inpatient Notes: mistakes in the hospital—communicating, apologizing, and beyond.

Kachalia A. Ann Intern Med. 2016;165:HO2-HO3.


Standardization of inpatient handoff communication.

Jewell JA; Committee on Hospital Care. Pediatrics. 2016;138:e20162681.

ASHP IV Adult Continuous Infusions.

Bethesda, MD: American Society of Health-System Pharmacists; 2016.


Improving Patient Safety Through Learning Laboratories.

Rockville, MD: Agency for Healthcare Research and Quality; December 2016.


A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation.

Agency for Healthcare Research and Quality. February 7, 2017; 2:00–3:30 PM (Eastern).

Third National Primary Care Ambulatory Patient Safety Conference in Research and Education.

American Academy of Pediatrics. February 23–24, 2017; Hyatt Regency Bethesda, Bethesda, Maryland.

Also of Note

Patient Safety Executive Development Program.

Institute for Healthcare Improvement. March 2–8, 2017; The Charles Hotel, Cambridge, MA.

2017 International Symposium on Human Factors and Ergonomics in Health Care: Improving the Outcomes.

Human Factors and Ergonomics Society. March 5–8, 2017; Sheraton New Orleans, New Orleans, Louisiana.

WebM&M; Cases

The Missing Abscess: Radiology Reads in the Digital Era

  • Spotlight Case

Commentary by Eliot L. Siegel, MD

Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.

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Hazards of Loading Doses

Commentary by Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD

An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

A Potent Medication Administered in a Not So Viable Route

Commentary by Osama Loubani, MD

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

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Perspectives on Safety

Workplace Safety


In Conversation With… Paul H. O'Neill, MPA

Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.


Workplace Safety in Health Care

Ross W. Simon and Elena G. Canacari, RN

This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.

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