Patient Safety Meetings & Articles
Meetings & Conferences
Board Engagement in Quality Improvement and Patient Safety
Baylor Health Care System STEEEP Global Institute. February 28–March 1, 2014; STEEEP Academy Training Facility, Baylor Health Care System, Dallas, TX
New York Meeting/Conference
Medical Diagnosis: Help Your Doctor Help You.
PULSE of New York. March 3, 2014; 5:00–9:30 PM; Holiday Inn Plainview, Long Island, NY.
New Mexico Meeting/Conference
Attaining High Reliability and Safety for Patients.
Patient Safety Collective of the Southwest. March 6–7, 2014; Sandia Resort and Casino, Albuquerque, NM.
Patient Safety Executive Development Program.
Institute for Healthcare Improvement. March 6–12, 2014; The Charles Hotel, Cambridge, MA.
Moving Forward with Patient- and Family-Centered Care.
Institute for Patient- and Family-Centered Care. March 31-April 4, 2014; San Francisco Airport Marriott Waterfront: Burlingame, CA.
CUSP Implementation Workshop.
Armstrong Institute for Patient Safety and Quality. April 2-3, 2014; Constellation Energy Building Conference Center, Baltimore, MD.
The Role of the Board in Quality and Safety.
Institute for Healthcare Improvement. April 3–4, 2014; The Charles Hotel, Cambridge, MA.
Creating a Culture of Patient Safety Workshop.
Virginia Mason Institute. April 9–11, 2014; Seattle, WA.
Articles & Publications
*Especially interesting article!
Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258:856-871. (This systematic review found that safety checklists in the operating room measurably augment teamwork and communication, which may explain how they improve patient outcomes)
Wang Y, Eldridge N. Metersky ML, et al. National trends in patient safety for four common conditions, 2005–2011. N Engl J Med. 2014;370:341-351. (Significant decline in adverse events for acute MI and CHF; no improvements in adverse events for pneumonia or surgical conditions)
Shake JG, Pronovost PJ, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications. J Card Surg. 2013;28:406-413. (Outline of advances in care of open heart surgery patient; focus on checklists and goal sheets)
Martinez EA. Quality, patient safety, and the cardiac surgical team. Anesthesiol Clin. 2013 Jun;31(2):249-68. doi: 10.1016/j.anclin.2013.01.004. Epub 2013 Mar 16. (Reviews quality and safety issues in cardiac surgery; offers strategies for improving both)
Abramson EL, Malhotra S, Osorio SN, et al. A long-term follow-up evaluation of electronic health record prescribing safety. J Am Med Inform Assoc. 2013 Apr 11; [Epub ahead of print]. (Initially high prescribing error rate with institution of new EHR; other studies report it takes one year to realize benefits of new EHR)
Gurses AP, Kim G, Martinez EA, et al. Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study. BMJ Qual Saf. 2012;21:810-818
Sanghavi D. Medical malpractice: why is it so hard for doctors to apologize? Boston Globe Magazine. January 27, 2013. (Discusses new “disclosure-and-offer” programs to replace older “deny-and-defend” approach to possible malpractice claims)
O'Reilly KB. Top 10 ways to improve patient safety now. American Medical News. April 15, 2013
Freeman R, McKee S, Lee-Lehner B, Pesenecker J. Reducing Interruptions to Improve Medication Safety. J Nurs Care Qual. 2012 Oct 23. [Epub ahead of print] (A group of practices to reduce interruptions and subsequent errors during medication administration)
Chu MW, Stitt LW, Fox SA, Kiaii B, Quantz M, Guo L, Myers ML, Hewitt J, Novick RJ. Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures. Arch Surg. 2011 Sep;146(9):1080-5. Epub 2011 May 16. (No difference in mortality in 0-3hrs sleep, 3-6hrs sleep, and >6hrs sleep)
Becker DJ. Do hospitals provide lower quality care on weekends? Health Serv Res. 2007 Aug;42(4):1589-612. (Patients admitted on weekend with myocardial infarction have higher rates of adverse outcomes; discussion of improving hospital staffing on weekends)
Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery?: An experimental prospective study. Ann Surg. 2012 Jul 20; [Epub ahead of print]. (20 second break every 20 minutes of operating may help)
Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med. 2012;40:2109-2115. (Standardized handover tool decreased postoperative complications)
Shaw G. Most adverse events at hospitals still go unreported. The Hospitalist. August 2012.
Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215;193-200.
AHRQ 2010 Annual Conference Presentations
Rockville, MD: Agency for Healthcare Research and Quality; November 2010.
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A Policy-based Intervention for the Reduction of Communication Breakdowns in Inpatient Surgical Care: Results From a Harvard Surgical Safety Collaborative. Ann Surg 2010
Cahan MA, Larkin AC, Starr S, et al., A human factors curriculum for surgical clerkship students. Arch Surg. 2010;145:1151-1157.
*Campbell DA, Jr. Physician wellness and patient safety. Ann Surg 2010; 251:1001-1002
*Carayon P, Buckle P. Editorial for special issue of applied ergonomics on patient safety. Appl Ergon 2010; 41:643-644 (An excellent resource for information on ergonomics and its relevance to surgery and patient safety.)
de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA., Prevention of surgical malpractice claims by a surgical safety checklist. Ann Surg. 2011 Jan 4.
*Gawande A., The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748. (The background to development of the WHO Surgical Safety Checklist.)
Gunderman R, Lynch J, Harrell H. A hazard of impatient medicine. The Atlantic. September 3, 2013. (Reductions in time for patient contact have consequences)
Halverson AL, Casey JT, Andersson J, et al., Communication failure in the operating room. Surgery 2010 Oct 15; [Epub ahead of print].
Joint Commission Resources; Safe Surgery Guide. Oakbrook Terrace, IL: 2010. ISBN: 9781599404073.
Kachalia A, Kaufman SR, Boothman R, et al., Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213-221.
Livingston EH. Solutions for improving patient safety. JAMA 2010; 303:159-161
Medical Malpractice and Errors. Health Aff (Millwood). 2010;29:1564-1619. (A complete issue devoted to the problem.
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff (Millwood) 2010; 29:1569-1577.
Nagpal K, Vats A, Lamb B, et al., Information transfer and communication in surgery: a systematic review. Ann Surg. 2010;252:225-239.
Pronovost PJ, Holzmueller CG, Ennen CS, Fox HE., Overview of progress on patient safety. Am J Obstet Gynecol. 2011;204:5-10.
Ross PT, McMyler ET, Anderson SG, et al. Jt Comm J Qual Patient Saf. 2011;37:88-95., Trainees' perceptions of patient safety practices: recounting failures of supervision.
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010; 251:995-1000
Sibinga EM, Wu AW. Clinician mindfulness and patient safety. JAMA 2010; 304:2532-2533
Sparks EA, Wehbe-Janek H, Johnson RL, Smythe WR, Papaconstantinou HT. Surgical Safety Checklist Compliance: A Job Done Poorly! J Am Coll Surg. 2013 Aug 21. pii: S1072-7515(13)00902-2. doi: 10.1016/j.jamcollsurg.2013.07.393.(Participation/completion of surgical checklists high, but accuracy of information lower than expected)
Sugden C, Aggarwal R, Darzi A. Re: Sleep deprivation, fatigue, medical error and patient safety. Am J Surg 2010; 199:433-434
Telem DA, Buch KE, Ellis S, Coakley B, Divino CM., Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. Arch Surg. 2011;146:89-93.
*Wachter RM. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood) 2010; 29:165-173. (What we have and have not accomplished since “To Err is Human.”)
Wahr JA, Prager RL, Abernathy JH 3rd, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, Council on Quality of Care and Outcomes Research. Circulation. 2013 Aug 5. (AHA statement on cardiac OR safety; nice summary statements throughout manuscript)
Walton M, Woodward H, Van Staalduinen S, et al. The WHO patient safety curriculum guide for medical schools. Qual Saf Health Care 2010; 19:542-546
Wiegmann DA, Dunn WF. Changing culture: a new view of human error and patient safety. Chest 2010; 137:250-252
Wiegmann DA, Eggman AA, Elbardissi AW, et al. Improving cardiac surgical care: a work systems approach. Appl Ergon 2010; 41:701-712
Wolf FA, Way LW, Stewart L., The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Ann Surg. 2010;252:477-485.
Youngson GG, Flin R. Patient safety in surgery: non-technical aspects of safe surgical performance. Patient Saf Surg 2010; 4:4