RESOURCES BY TOPIC

INDEX of TOPICS:
 A - C  C - H  H - M  M - R  R - Z
 Accreditation and Safety Standards
 Adult Hospitals and the Care of Children
 Adverse Event Detection and Trigger Tools
 Alarm Fatigue
 Alert Fatigue
 Ambulatory Care
 Anaesthesia
 Anaphylaxis
 Antibiotic Resistance
 Awards and Success Stories
 Bar Code Medication Administration (BCMA)
 Beds and Cribs
 Big Data and Predictive Analytics
 Business Case for Patient Safety
 Cardiology
 Change Management
 Child Abuse
 Child Health in the Community
 Child Safety and Injury Prevention
 Child Survival in Developing Countries
 Clinical Decision Support System (CDSS)
 Clinical Effectiveness and Standardisation
 Clinical Pathways
 Clinical References
 Communication
 Continuous Improvement and Lean
 Continuous Monitoring
 CPR and Resuscitation
 Critical Care
 Daily Goals
 Deterioration
 Developing Countries and Resource-Poor Settings 
 Diagnosis
 Disaster Preparedness
 Discharge Timeliness
 Disclosure
 Disparities and Equity
 Duty Hours
 Ebola
 Education and Training
 eHealth, mHealth, and Telehealth
 Eliminating Preventable Harm
 Emergency Care
 Emergency Medical Services (EMS)
 Employee Safety
 Flow
 General/Community Hospitals
 Global Child Health
 Haematology/Oncology
 Hand Hygiene
 Handoffs and Communication
 Health IT
 Health Literacy
 High Reliability and HROs
 Hospital Acquired Conditions (HACs):
 - ADE
 - CAUTI
 - CLABSI
 - Falls
 - OB-AE 
 - PIVIE
 - PU
 - SSI 
 - Unplanned Extubations
 - VAP
 - VTE
 Hospital Acquired Infections (HAIs)
 Hospital at Night (HaN)
 Hospital Design
 Huddles
 Human Factors
 Journals
 Junior Doctors
 Leadership
 Malpractice
 Medical Devices
 Medical Emergency Team (MET)
 Medical Errors
 Medication Safety
 Mental Health
 Mislabeled Specimens
 Morbidty and Mortality (M&M) Rounds
 National Patient Safety Board
 Neonatal Intensive Care Unit (NICU)
 Neonatal-Perinatal
 Never Events
 Opioids
 Paediatric Early Warning System (PEWS)
 Paediatric Intensive Care Unit (PICU)
 Pain
 Patient and Family Engagement
 Patient Identification
 Patient Safety Indicators (PSIs)
 Patient Safety Priority Areas
 Peer-to-Peer (P2P) Assessment
 Poisoning Prevention
 Precision Public Health
 Prehospital Care
 Primary Care
 Quality Measures
 Radiation in Imaging
 Rapid Response Team (RRT)
 Readmissions and Care Transitions
 Reporting 
 Researcher-in-Residence
 Resident Physicians
 Resuscitation
 Reverse Innovation
 Root Cause Analysis (RCA)
 Safety Culture
 Safety-II and Resilience
 Second Victim
 Sentinel Events 
 Sepsis
 Serious Safety Events (SSEs)
 Simulation
 Situation Awareness
 Sleep and SIDS
 Staffing
 Standardisation of Care
 Surgery
 Teamwork Training    
 Telemedicine   
 Transport
 Trigger Tools
 Triple Aim
 Tubing Misconnections
 Universal Health Coverage
 Unplanned Extubations
 Walkrounds
 Weekend Effect
 Work Environment
 Zika
       
 

RESOURCES by TOPIC:
 Accreditation and Safety Standards  ACSQHC - accreditation and the NSQHS standards
 ISQua - International Accreditation Programme (IAP)
 Joint Commission International (JCI) 
 Patient mortality during unannounced accreditation surveys at US hospitals
 PIPSQC - protecting children from harm - setting standards: a view from Australia (slides) 
 PIPSQC - protecting children from harm - setting standards: a view from the UK (slides)
 SafeCare - SafeCare Standards - for health centres in resource-restricted settings 
 Secret data on hospital inspections may soon become public
 Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial
 When clinicians know they're being watched, patients fare better
 Adult Hospitals and the Care of Children  Emergency Department: 
 AAP - joint policy statement - guidelines for care of children in the emergency department 
 CMS - PfP library - guidelines for care of children in the emergency department 
 Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU
 National assessment of pediatric readiness of emergency departments
 National Pediatric Readiness Project (Peds Ready) - ensuring emergency care for all children
 National Pediatric Readiness Project (Peds Ready) - readiness toolkit

 Inpatient:
 AAP - Section on Hospital Medicine (SOHM) - elibrary 
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions 
 CMS - PfP - resources 
 CMS - PfP library - adverse drug event priority areas for pediatric patients
 CMS - PfP library - care of children in general hospitals 
 CMS - PfP library - children are not little adults
 CMS - PfP library - ensuring pediatric safety in general hospitals 
 CMS - PfP library - PFE (patient and family engagement) guidelines for pediatric patients in adult hospitals 
 CMS - PfP library - resource list for pediatric safe care
 HRET - Hospital Engagement Network (HEN) 2.0 - topics 
 Pediatric medication safety in adult community hospital settings: a glimpse into nationwide practice
 UHN - Caring Safely (slides)
 Adverse Event Detection and Trigger Tools  Adverse Drug Events:
 30-day potentially avoidable readmissions due to adverse drug events
 Adverse drug event reporting systems: a systematic review
 Assessing frequency and risk of weight entry errors in pediatrics
 Automated detection of look-alike/sound-alike medication errors
 Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database
 CHA - saving lives and reducing medication errors with data
 Clinical decision support for drug related events: moving towards better prevention
 IHI - pediatric trigger toolkit: measuring adverse drug events in the children's hospital
 IHI - trigger tool for measuring adverse drug events
 Learning from the design, development and implementation of the Medication Safety Thermometer
 Looking for safety insights in medication order changes
 National trends in safety performance of electronic health record systems in children's hospitals
 NHS - Medication Safety Thermometer
 Screening for medication errors using an outlier detection system
 
 Electronic: 
 Assessing frequency and risk of weight entry errors in pediatrics
 Automated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions
 Automated detection of adverse events in children 
 Big data applied to patient safety in children's hospitals
 Casting a wider safety net: the promise of electronic safety event detection systems
 CHA - what big data means for pediatrics
 Developing and evaluating an automated all-cause harm trigger system
 Development of an electronic pediatric all-cause harm measurement tool using a modified delphi method 
 Electronic approaches to making sense of the text in the adverse event reporting system
 Innovative use of the electronic health record to support harm reduction efforts
 IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety
 National trends in safety performance of electronic health record systems in children's hospitals
 New 'trigger tool' scans EMRs for harms in pediatric hospitals
 Pediatric hospitals show wide gap in EHR safety performance
 Screening electronic health record–related patient safety reports using machine learning

 Emergency Department:
 
Adverse event and error of unexpected life-threatening events within 24h of emergency department admission
 Development of an emergency department trigger tool using a systematic search and modified delphi process

 Inpatient: 
 Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study  
 Application of the global trigger tool: a systematic review
 CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review
 CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review 
 CPSI -  Canadian Paediatric Adverse Events Study (CPAES)
 Designing highly reliable adverse-event detection systems to predict subsequent claims
 Development of the Canadian paediatric trigger tool for identifying potential adverse events
 Development of a pediatric adverse events terminology
 Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU
 Families as partners in hospital error and adverse event surveillance
 IHI - introduction to trigger tools for identifying adverse events
 IHI - paediatric trigger tool for measuring adverse events (UK version)
 IHI - perinatal trigger tool
 IHI - trigger tool for measuring adverse events in the neonatal intensive care unit
 Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer - guidance
 NHS - Neonatal Trigger Tool (NTT) 
 NHS - organisation patient safety incident reports
 NHS - Paediatric Trigger Tool (PTT) 
 NHS - Safety Thermometer (Classic) 
 Operational failures detected by frontline acute care nurses
 Pediatric terminology files - "pediatric adverse events terminology"
 Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool
 Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the paediatric trigger tool 
 Trigger tool to detect harm in pediatric inpatient settings 

 Outpatient:   
 
CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review
 CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review
 IHI - outpatient adverse event trigger tool
 Patient safety incidents are common in primary care: a national prospective active incident reporting survey
 Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis
 Safety incidents in the primary care office setting
 Sick children crying for help: fostering adverse event reports

 General:
 Canadian hospitals can reduce risk of patient harm, report says
 CIHI - 1 in 18 patients experiences harm in Canadian hospitals
 CIHI - hospital harm project
 CPSI - hospital harm indicator 
 CPSI - measuring patient harm in Canadian hospitals
 Design and reliability of a specific instrument to evaluate patient safety for patients with acute myocardial infarction treated in a predefined care track: a retrospective patient record review study in a single tertiary hospital in the Netherlands
 Estimating deaths due to medical error: the ongoing controversy and why it matters 
 Estimating hospital-related deaths due to medical error: a perspective from patient advocates
 Health Foundation - framework for measuring and monitoring safety
 Health Foundation - measurement and monitoring of safety
 Hospital Safety Grade - lives lost and lives saved
 Implementation of the trigger review method in Scottish general practices: patient safety outcomes and potential for quality improvement
 IOM - to err is human - building a safer health system
 Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals - a retrospective record review study
 ISMP - using information from external errors to signal a "clear and present danger"
 Measurement as a performance driver: the case for a national measurement system to improve patient safety
 Measuring harm in health care: optimizing adverse event review
 Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study
 Medical error-the third leading cause of death in the US 
 NHS England - Development of the Patient Safety Incident Management System (DPSIMS)
 Performance of a trigger tool for identifying adverse events in oncology
 Study on medical error as third cause of US deaths criticized as 'precarious' 
 Stunning news on preventable deaths in hospital
 Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events
 Why are medical errors still a leading cause of death?
 Alarm Fatigue  Paediatric:
 Big data applied to patient safety in children's hospitals 
 Development of heart and respiratory rate percentile curves for hospitalized children
 Framework for reducing alarm fatigue on pediatric inpatient units 
 Frequency of physiologic monitor alarms in a children's hospital
 Predictive analytics: heading off the alarms at Boston Children’s Hospital 
 Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital

 General:
 
ACCN - strategies for managing alarm fatigue 
 AHRQ PSNet - reducing the safety hazards of monitor alert and alarm fatigue 
 Alarm fatigue: use of an evidence-based alarm management strategy
 Ambient Clinical Analytics - AWARE - addressing the information overload issue to reduce risk and improve patient outcomes 
 Bernoulli - alarm management
 Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU           
 How redesigning the abrasive alarms of hospital soundscapes can save lives
 New for 2016: Joint Commission updates alarm guidelines
 NPSF - surveillance monitoring for all
 Raising an alarm, doctors fight to yank hospital ICUs into the modern era
 Alert Fatigue  Clinical reasoning in the context of active decision support during medication prescribing
 Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system
 Evaluation of medication-related clinical decision support alert overrides in the intensive care unit
 Optimization of drug-drug interaction alert rules in a pediatric hospital's EHR using a visual analytics dashboard 
 Screen flashes and pop-up reminders: ‘alert fatigue’ spreads through medicine
 Ambulatory Care  AAP - Practice Improvement Network (PIN) 
 Addressing ambulatory safety and malpractice: the Massachusetts PROMISES project
 AHRQ - guide to improving patient safety in primary care settings by engaging patients and families
 AHRQ - making health care safer in ambulatory care settings and long term care facilities (grant)  
 AHRQ - taking steps to protect safety in ambulatory care
 Annotated bibliography: understanding ambulatory care practices in the context of patient safety and quality improvement
 CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development
 CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review
 CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review
 How to monitor patient safety in primary care
 Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care
 Medication errors in outpatient pediatrics
 NPSF - creating structure for sharing information and knowledge in ambulatory care: two exemplars
 NPSF - swinging the patient safety pendulum to primary care
 Patient safety in ambulatory care 
 Patient safety in ambulatory settings
 Patient safety incidents are common in primary care: a national prospective active incident reporting survey
 Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis
 Preventing diagnostic errors in primary care
 Role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice
 Safety incidents in the primary care office setting
 Sick children crying for help: fostering adverse event reports
 Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports
 Taking steps to protect safety in ambulatory care
 WHO - safer primary care 
 WHO - technical series on safer primary care
 Anaesthesia  A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong
 APSF - monitoring for opioid-induced ventilatory impairment (OIVI)
 Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study
 Certified registered nurse anesthetist perceptions of factors impacting patient safety
 Development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists
 Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation
 Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis
 Interventions guided by analysis of quality indicators decrease the frequency of laryngospasm during pediatric anesthesia
 Managing Emergencies in Paediatric Anaesthesia (MEPA)
 Medication safety in the operating room: literature and expert-based recommendations
 Monitoring the anaesthetist in the operating theatre-professional competence and patient safety
 National pediatric anesthesia safety quality improvement program in the United States 
 PIPSQC - to sleep perchance to dream - quality in pediatric anesthesia 
 Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome? 
 Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system
 Society for Pediatric Anesthesia (SPA)
 Wake Up Safe - pediatric anesthesia quality improvement initiative 
 What parents should know about the use of general anesthesia in toddlers
 Anaphylaxis  15 per cent of kids who have an anaphylactic reaction have delayed second reaction: study
 Determining current insulin pen use practices and errors in the inpatient setting
 Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis
 Lacerations and embedded needles caused by epinephrine autoinjector use in children
 Medication errors in the management of anaphylaxis in a pediatric emergency department
 Antibiotic Resistance  5 ways you can help prevent the post-antibiotic era
 Antimicrobial resistance
 Antimicrobial stewardship and patient safety
 CDC - antibiotic / antimicrobial resistance 
 CDC - pressing fast forward on patient safety 
 Cooperative high reliability organization: approaching a zero-defect culture
 Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative
 IDSA - antimicrobial resistance
 MRSA rates dropped 87% in VA hospital ICUs
 New hope in superbug fight: Tasmanian devil milk
 NPSF - five ways to take action against antibiotic resistance
 NQF - antibiotic stewardship playbook
 NQF - NQF, CDC issue guidance to help hospitals better manage use of antibiotics 
 Science world is freaking out over this 25-year-old's answer to antibiotic resistance 
 'Superbug' scourge spreads as U.S. fails to track rising human toll
 Superbugs: the $100 trillion risk
 UN adopts declaration on antimicrobial resistance
 WHO - antimicrobial resistance
 WHO - evolving threat of antimicrobial resistance - options for action  
 WHO - global action plan on antimicrobial resistance
 WHO - guidelines on core components of infection prevention and control programmes at the national and acute health care facility level
 WHO - WHO publishes list of bacteria for which new antibiotics are urgently needed
 Awards and Success Stories  Africa: 
 
Nelson Mandela Children’s Hospital Trust - about us (South Africa) 
 Nelson Mandela Children’s Hospital Trust to bring state-of-the-art healthcare to the children of Africa
 SickKids - SickKids and the Nelson Mandela Children's Hospital
 
 Asia:
 
KK Women's and Children's Hospital - patient safety - building a reliable culture for a sustainable outcome

 Europe: 
 Getting better: the inside track on improving Great Ormond Street Hospital
 Great Ormond Street Hospital for Children (GOSH) - quality improvement
 Health Foundation - pursuing zero - a winning approach to safety 
 NHS England - integrated digital care record - success story: safer hospitals, safer wards technology fund (Nottingham University Hospitals)

 North America:
 AHA - Children's Colorado - Target Zero: data and a personal touch to improve young patients' safety
 AHA - Nationwide Children's - reducing harm is great: eliminating it is the ultimate goal
 AHA - HPOE - Children's Colorado and Nationwide Children's quality and safety journey (slides) 
 AHA - HPOE - Children's Colorado and Nationwide Children's quality and safety journey (webinar)
 AHA - HPOE - profiles in excellence: quality improvement lessons from the AHA-Mckesson Quest for Quality Prize recipients part 1 
 AHRQ - impact case studies
 AHRQ - improving patient safety through learning laboratories
 'Being the best at getting better' - creating a culture of change (Cincinnati Children's)
 Building a high-reliability organization: one system's patient safety journey
 CHA - 4 quality improvement ideas hospitals can implement
 CHA - 2015 Pediatric Quality Award entries (by hospital) 
 Children's Colorado - always improving: what we measure and how we do it
 Eliminating preventable harm to patients and staff (SickKids)
 John M. Eisenberg Patient Safety and Quality Awards 
 OHMCH celebrates 365 days without a serious safety event
 Nationwide Children's - Nationwide Children's hospital receives award from CHA for 'Zero Hero' patient safety program  
 NPSF - awards
 PIPSQC - mission possible (high reliability at Rainbow Children's)
 PIPSQC - Target Zero at Children’s Colorado: eliminating preventable harm 
 SickKids - Caring Safely - our journey to eliminating preventable harm
 'We're not going to compete on safety': Canadian paediatric health centres collaborate on journey to eliminating preventable harm
 Bar Code Medication Administration (BCMA)  Bar code Rx administration compliance rolling out slowly
 Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification
 Comparison of medication safety systems in critical access hospitals: combined analysis of two studies
 Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework 
 Effect of barcode-assisted medication administration on emergency department medication errors
 Effects of bar-coding technology on medication errors: a systematic literature review
 Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events
 Improved supply chain in Canadian health system can save lives
 NPSF - medication barcode optimization 
 OhioHealth improves patient safety with processes and advanced technologies
 Pediatric medication administration errors and workflow following implementation of a bar code medication administration system
 Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode
 Supermarket-style scanners could make health care safer: study
 WIN - visibility: the new value proposition for health systems 
 WIN - visibility: the new value proposition for health systems (slides)
 WIN - visibility: the new value proposition for health systems - executive summary
 Beds and Cribs  FDA pediatric hospital bed regulations
 FDA - summary: general hospital and personal use devices: renaming of pediatric hospital bed classification and designation of special controls for pediatric medical crib; classification of medical bassinet (proposed rule) 
 Big Data and Predictive Analytics  Paediatric:
 Big data applied to patient safety in children's hospitals 
 CHA - what big data means for pediatric patients
 Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children 
 Isansys - available now - new data driven approach to healthcare
 Looking for safety insights in medication order changes 
 PEDSnet 
 Precision public health: big data's next big idea
 Predictive analytics: heading off the alarms at Boston Children’s Hospital

 General: 
 Big data in healthcare made simple: where it stands today and where it’s going
 Finding the missing link for big biomedical data 
 Perspectives on big data, ethics, and society
 Business Case for Patient Safety  Paediatric: 
 Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population
 CHA - investing in children should be a national priority
 Children's Hospitals' Solutions for Patient Safety (SPS) - our results 
 Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2016)
 Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2015) 
 Children's Hospitals' Solutions for Patient Safety (SPS) - Ohio Children's Hospitals release results of Ohio patient safety collaboration; demonstrate national impact of work 
 Cincinnati Children's - CERT - learning network health care outcomes
 Comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality 
 Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system
 NPSF - making quality and safety a priority in health care for our children
 Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement

 General: 
 AHRQ - national patient safety efforts save 125,000 lives and nearly $28 billion in costs
 AHRQ - national quality strategy - making care safer 
 AHRQ - national scorecard on rates of hospital-acquired conditions 2010 to 2015: interim data from national efforts to make health care safer
 AHRQ - saving lives and saving money: hospital-acquired conditions update - interim data from national efforts to make care safer, 2010-2014
 AHRQ - we're keeping score: reducing hospital-acquired conditions
 Canadian hospitals can reduce risk of patient harm, report says
 CIHI - hospital harm project
 CMS awards $347 million to continue progress toward a safer health care system
 CMS - continuing to improve patient safety in hospitals 
 CMS - Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 - final report
 CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm
 Cost-benefit analysis of a support program for nursing staff
 Deaths by medical mistakes hit records
 Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes
 Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review
 Economic impact of medication error: a systematic review
 Federal ministry of health - economics of patient safety: strengthening a value-based approach to reducing patient harm at national level
 From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system
 Healthy life-years lost and excess bed-days due to 6 patient safety incidents: empirical evidence from English hospitals
 HHS.gov - national patient safety efforts save 87,000 lives and nearly $20 billion in costs
 Hospital Engagement Network Results Show 34,000 Harms Prevented
 Hospital Safety Grade - lives lost and lives saved
 IHI/NPSF - optimizing a business case for safe health care: an integrated approach to safety and finance
 IHI/NPSF - webcast: business case for patient safety
 Impact of inpatient harms on hospital finances and patient clinical outcomes 
 Impact of medical errors and malpractice on health economics, quality, and patient safety
 Impact of Medicare's nonpayment program on hospital-acquired conditions
 Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System
 New study shows financial benefit of improving patient safety 
 NPSF - preventable health care harm is a public health crisis
 PIPSQC - patient harm is a public health crisis, not just a performance management issue 
 Preventable harm in healthcare a public health crisis
 Scottish Government - 20,000 fewer deaths than expected since safety programme launched
 Stunning news on preventable deaths in hospital
 Cardiology  CHA - advancing care for children with heart defects
 International Children's Heart Foundation (ICHF) - where we operate
 International Quality Improvement Collaborative for Congenital Heart Surgery in Developing World Countries (IQIC) 
 National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) 
 Pediatric Cardiac Critical Care Consortium (PC4)
 Save a Child's Heart - global
 Change Management  Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups
 IHI - sustaining improvement
 Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature
 Highly Adoptable Improvement Model
 HIS - QI Connect - high leading and networking for change
 How to create change that sticks and spreads
 How hospital workers solve patient-safety problems on their own
 IGNITE Consulting
 Promising contributions of behavioral economics to quality improvement in health care
 Slow ideas
 What we know about designing an effective improvement intervention (but too often fail to put into practice)
 Child Abuse  AAP - Section on Child Abuse and Neglect (SOCAN)
 Child abuse evaluation & treatment for medical providers - a-z index 
 Child maltreatment: a public health overview and prevention considerations 
 End Violence Against Children - The Global Partnership
 HSCIC - Child Protection – Information Sharing project (CP-IS)
 International Society for the Prevention of Child Abuse and Neglect (ISPCAN) 
 RCPCH - child protection 
 UNICEF - child protection from violence, exploitation and abuse 
 Child Health in the Community  AAP - healthychildren.org 
 Canada, the kids are not alright
 CHA - adults say kids' health is worse than the past
 CHA - investing in the future of children's health
 CHA - lessons learned in the first 18 months of the CARE Award to transform care and payment models
 CHA - health care model that prevents childhood obesity
 Cincinnati Children Thrive Learning Network (CCTLN)
 IHI - 100 Million Healthier Lives 
 ihub Scotland - support in the community - Scottish Patient Safety Programme - maternity and children's care
 International Pediatric Association (IPA) - children's environmental health and the sustainable development goals
 National Center for Education in Maternal and Child Health (NCEMCH) - professional resource guides and briefs
 National Institute for Children’s Health Quality (NICHQ) - project topic areas 
 NHS Choices - child health tools 
 NPSF - preventable health care harm is a public health crisis
 Patient safety: a public health crisis for a nation of patients
 PIPSQC Blog - patient harm is a public health crisis, not just a performance management issue
 Preventable harm in healthcare a public health crisis
 Scottish Government - Early Years Collaborative (EYC) 
 Scottish Government - Getting it Right for Every Child (GIRFEC)
 SickKids - AboutKidsHealth
 Speak Now for Kids - Advancing Care for Exceptional Kids Act of 2015 (ACE Kids Act)
 WHO - cost of a polluted environment: 1.7 million child deaths a year, says WHO
 Child Safety and Injury Prevention  CAPHC - new CPS position statement: The prevention of firearm injuries in Canadian youth
 CDC - national action plan for child injury prevention 
 CHA - give families the tools to store firearms safely
 Children's Safety Network (CSN) - injury topics 
 Children's Safety Network (CSN) - Child Safety Collaborative Innovation and Improvement Network (CS COIIN) 
 KidsAndCars.org
 Safe Kids Worldwide 
 Safe Kids Worldwide: preventing unintentional childhood injuries across the globe 
 SickKids - a child is injured by a firearm every day in Ontario: study
 WHO - child injuries and violence
 WHO - international and regional child safety organizations
 WHO - more than 1.2 million adolescents die every year, nearly all preventable
 Child Survival in Developing Countries  Maternal, Newborn, and Child Survival: 
 Adoption of recommended practices and basic technologies in a low-income setting
 Bill & Melinda Gates Foundation - maternal, newborn & child health 
 CAPHC - Pocket Doc for Pneumonia: top 10 Google.org impact challenge finalist
 Coalition of Centres in Global Child Health
 DCP3 - reproductive, maternal, newborn, and child health - key messages 
 Delivering for mothers and newborns: ending preventable maternal and newborn deaths
 Ending Preventable Child and Maternal Deaths - A Promise Renewed (APR) 
 Every Newborn
 Every Woman, Every Child 
 Every Woman, Every Child - launch of global accelerated action for the health of adolescents (AA-HA!): guidance to support country implementation
 Every Woman, Every Child - transitioning the global strategy for women’s and children’s health for the post-2015 era
 Gavi - global vaccine alliance - progress reports
 Global burden of diseases for young people's health during 1990-2013
 Healthy Newborn Network (HNN) 
 Healthy Newborn Network (HNN) - saving newborn lives - champions toolkit
 Helping Babies Breathe
 International Pediatric Association (IPA) - child survival 
 International Pediatric Association (IPA) - children's environmental health and the sustainable development goals
 International Pediatric Association (IPA) - joint statements - managing possible serious bacterial infection in young infants 0-59 days old when referral is not feasible
 Jhpiego 
 Johns Hopkins School of Public Health receives $20 million grant from the Bill & Melinda Gates Foundation to improve third world maternal and child health
 Laerdal Global Health 
 Maikhanda Trust (Malawi) 
 Nelson Mandela Children’s Hospital Trust - reduce child mortality in Sub-Saharan Africa
 OPENPediatrics - addressing child survival globally (webinar) 
 OPENPediatrics - development of triage guidelines for the PICU (South Africa) (webinar)
 OPENPediatrics - international web-based pediatric knowledge network - resources 
 Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score
 Save the Children - Saving Newborn Lives (SNL) program
 Saving Lives at Birth 
 SDGs: start with maternal, newborn, and child health cluster
 SickKids Centre for Global Child Health 
 SickKids - Coalition of Centres in Global Child Health
 Sprinkles Global Health Initiative - to prevent and treat micronutrient deficiencies
 Towards ending preventable child deaths
 UCR - maternal, newborn, and child health
 UN - sustainable development knowledge platform - goal 3: ensure healthy lives and promote well-being for all at all ages 
 UNICEF - narrowing the gaps - the power of investing in the poorest children
 UNICEF - UNICEF Annual Report 2016 
 USAID - Alliance for Reproductive, Maternal, and Newborn Health (2010 - 2015) 
 USAID - Every Child Deserves a 5th Birthday - global roadmap 
 USAID - maternal child survival program  
 WHO - almost half of all deaths now have a recorded cause, WHO data show
 WHO - children: reducing mortality
 WHO - Collaborating Center for Training and Research in Newborn Care 
 WHO - cost of a polluted environment: 1.7 million child deaths a year, says WHO
 WHO - Integrated Management of Childhood Illness (IMCI) 
 WHO - joint United Nations statement on ending discrimination in health care settings
 WHO - management of newborn illness and complications
 WHO - managing possible serious bacterial infection in young infants when referral is not feasible
 WHO - maternal, newborn, child and adolescent health 
 WHO - monitoring priorities for the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030)
 WHO - more than 1.2 million adolescents die every year, nearly all preventable
 WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline
 WHO - Partnership for Maternal, Newborn & Child Health (PMNCH) 
 WHO - pocket book of hospital care for children - guidelines for the management of common illnesses with limited resources 
 WHO - PMNCH - PMNCH 2016 annual report
 WHO - promoting health through the life-course - resources and publications
 WHO - reaching the Every Newborn national 2020 milestones - country progress, plans and moving forward
 WHO - world health assembly agrees resolutions on women, children and adolescents, and healthy ageing 
 Worldmapper - infant mortality

 Patient Safety and Quality: 
 Access Health International - maternal and child health
 Best Care... Always! (South Africa) 
 Can a quality improvement project impact maternal and child health outcomes at scale in northern Ghana?
 Federal Ministry of Health - best practices in patient safety: 2nd global ministerial summit on patient safety
 Federal Ministry of Health - patient safety summit 2017 - patient safety takes the front seat
 Healthy Newborn Network (HNN) - India part of health network to reduce maternal, newborn deaths
 IHI - IHI's work in Africa
 IHI - IHI's work around the world 
 IHI - Project Fives Alive! - reducing under-5 mortality in Ghana 
 Improving the quality of paediatric care in peripheral hospitals in developing countries
 International Pediatric Association (IPA) - joint statements - improving quality of maternal and newborn care in low- and middle-income countries
 International Pediatric Association (IPA) - Quality of Care (QoC) 
 ISQua - Improving physician compliance to WHO guidelines for better health of pediatric population 
 Lancet - maternal health - an executive summary for The Lancet's series
 Nelson Mandela Children’s Hospital Trust - about us (South Africa) 
 OPENPediatrics - leading towards zero harm (webinar) 
 OPENPediatrics - improving safety in the PICU (webinar)
 OPENPediatrics - Pediatric Clinical Safety Investigation (CSI) - virtual patient safety rounds (#1-8) (webinars) 
 Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review 
 PICC 2016 - pre-congress workshops - global health 
 PICC 2016 - session summaries - global health session 
 Quality of care for pregnant women and newborns - the WHO vision
 Review of pediatric critical care in resource-limited settings: a look at past, present, and future directions
 SafeCare - SafeCare Standards - for health centres in resource-restricted settings 
 SickKids - SickKids and the Nelson Mandela Children's Hospital
 SickKids - SickKids partners with Nelson Mandela Children's Hospital Trust
 USAID ASSIST Project - maternal, newborn, and child health
 WHO - African Partnerships for Patient Safety (APPS) 
 WHO - better hospital care for children
 WHO - consultation on improving measurement of the quality of maternal, newborn and child care in health facilities
 WHO - hospital care for mothers and newborn babies quality assessment and improvement tool 
 WHO - improving paediatric quality of care at first-level referral hospitals
 WHO - launch of the network to improve quality of care for mothers, newborns and children
 WHO - maternal, newborn, child and adolescent health - documents on quality of care 
 WHO - patient safety - implementing change 
 WHO - PMNCH - launch of Network for Improving Quality of Care for Maternal, Newborn and Child Health
 WHO - quality of care for every pregnant woman and newborn 
 WHO - standards for improving quality of maternal and newborn care in health facilities
 Clinical Decision Support System (CDSS)  Ambient Clinical Analytics - Mayo Clinic and tech entrepreneurs join forces to launch Ambient Clinical Analytics, first-ever bedside decision support platform to transform patient critical care 
 American College of Physicians launches ACP Smart Medicine, offering doctors 'one click to confidence'
 Can computers help doctors reduce diagnostic errors?
 Clarity Informatics - evidence-based healthcare intelligence 
 Clinical decision support: 25 year retrospective and a 25 year vision
 Clinical decision support for drug related events: moving towards better prevention
 Deep learning is a black box, but health care won't mind
 Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation
 DXplain decision support system
 Effects of workload, work complexity, and repeated alerts on alert fatigue in a clinical decision support system
 'Green Button' for using aggregate patient data at the point of care
 IBM - WatsonPaths 
 Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis
 Impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients
 Innovative use of the electronic health record to support harm reduction efforts
 ISABEL Active Intelligence - diagnosis decision support system
 Learning health care system using computer-aided diagnosis
 National trends in safety performance of electronic health record systems in children's hospitals
 Pediatric hospitals show wide gap in EHR safety performance
 Screening for medication errors using an outlier detection system
 Zynx Health announces innovative line of analytic clinical improvement solutions 
 Clinical Effectiveness and Standardisation  Australia: 
 CareTrack Kids - CareTrack Kids main study conditions
 CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development
 CareTrack Kids - part 2. assessing the appropriateness of the healthcare delivered to Australian children: study protocol for a retrospective medical record review 
 NSW Health - Office of Kids and Families - standardisation of care 
 PIPSQC - protecting children from harm - setting standards: a view from Australia (slides) 
 PIPSQC - what percentage of children receive healthcare in line with clinical practice guideline recommendations?
 
 Europe: 
 Dartmouth Institute - where children live affects care, exposing some to unnecessary treatment, imaging and medication 
 Health Foundation - creating a new improvement research institute
 Mapping variation to prioritise areas needing improved outcome, quality and productivity
 PIPSQC - protecting children from harm - setting standards: a view from the UK (slides)

 North America: 
 AAP - Choosing Wisely - 10 things physicians and patients should question 
 CAPHC - Canadian Paediatric Decision Support Network (CPDSN)
 CAPHC - say yes to the less - Choosing Wisely program in a paediatric department
 Choosing Wisely campaign - don’t throw the baby out with the bathwater 
 Choosing wisely in newborn medicine: five opportunities to increase value 
 Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value
 Countering cognitive biases in minimising low value care
 Employer-led health care revolution
 Is excessive resource utilization an adverse event?
 Prioritization of comparative effectiveness research topics in hospital pediatrics 
 PRIS - PHIS+: augmenting the pediatric health information system with clinical data
 PRIS - prioritization project 
 Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support
 Reducing overuse - is patient safety the answer?
 Texas Children's hospital improves quality of care, identifies inefficiencies with enterprise data warehouse from Health Catalyst 
 Wennberg International Collaborative - research into causes of unwarranted health care variation
 Which inpatient pediatric conditions merit priority in comparative effectiveness research? 

 Global:
 International Consortium for Health Outcomes Measurement (ICHOM) - standard sets
 Clinical Pathways  Paediatric: 
 Boston Children's - when the going gets tough, the tough get data: SCAMPs (slides)
 Children's Hospital of Philadelphia (CHOP) - clinical pathways
 Cincinnati Children's - Evidence Based Decision Making (EBDM) 
 Clinical pathways - driving high-reliability and high-value care
 Seattle Children's - clinical standard work pathways and tools 
 Standardized Clinical Assessment and Management Plans (SCAMPs) - pediatric SCAMPs 
 TREKK - ED clinical pathways implementation

 General: 
 Clarity Informatics - Quality Improvement System (QIS) 
 NHS - Advancing Quality 
 Standardized Clinical Assessment and Management Plans (SCAMPs)
 Clinical References  AAP - Pediatric Care Online
 RCPCH - Paediatric Care Online UK
 Communication  See 'Handoffs and Communication'
 Continuous Improvement and Lean  Employer-led health care revolution
 Factory efficiency comes to the hospital 
 Healthier Hospitals Initiative 
 IHI - radically redesigning patient safety
 Lean Hospitals - Lean Hospitals; improving quality, patient safety, and employee engagement 3rd edition
 Lean Hospitals - resources 
 Modifying the toyota production system for continuous performance improvement in an academic children's hospital 
 Seattle Children's - CPI book: Leading the lean healthcare journey 
 Seattle Children's - CPI fact sheets 
 Seattle Children's - transformative healthcare via Continuous Performance Improvement (CPI)
 SickKids - daily Continuous Improvement Program (CIP) 
 SickKids - daily Continuous Improvement Program to provide safer care (slides)
 Virginia Mason - Virginia Mason production system
 Waste not, want not - the key to reducing costs
 Continuous Monitoring  See 'Critical Care'
 CPR and Resuscitation   AAP - updated guidelines address CPR, emergency cardiovascular care
 Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments
 Emergency Medical Services for Children (EMSC) National Resource Center - toolboxes 
 Helping Babies Breathe 
 ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients
 International Liaison Committee on Resuscitation (ILCOR)
 Monash Children's - pediatric emergency medication book 
 Pediatric Advanced Life Support (PALS)
 PICC 2016 - session summaries - resuscitation session
 PIPSQC - keeping kids safe during critical illness and resuscitation 
 Time to epinephrine and survival after pediatric in-hospital cardiac arrest 
 WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline
 Critical Care  Clinical Decision Support System (CDSS):
 Ambient Clinical Analytics - Mayo Clinic and tech entrepreneurs join forces to launch Ambient Clinical Analytics, first-ever bedside decision support platform to transform patient critical care 
 Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children
 Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures

 Continuous Monitoring: 
 Ambient Clinical Analytics - AWARE - addressing the information overload issue to reduce risk and improve patient outcomes 
 Birmingham Children's - RAPID (Real-Time Adaptive and Predictive Indicator of Deterioration)
 Boston Children's Hospital and Etiometry bring T3 patient-monitoring technology to market 
 Etiometry - Tracking, Trajectory, Trigger (T3) intensive care unit software solution 
 Formula 1 technology is helping save childrens lives
 Health Foundation - continuous remote monitoring of ill children (Birmingham Children's) 
 ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients
 Insights from multi-dimensional physiological signals to predict and prevent cardiac arrests
 Isansys - available now - new data driven approach to healthcare 
 Isansys - Isansys wearable technology and wireless patient monitoring platform in at-scale deployment at Birmingham Children's Hospital
 Monitoring: advanced technology in ICU (slides) 
 NPSF - surveillance monitoring for all
 Raising an alarm, doctors fight to yank hospital ICUs into the modern era
 'Smart pills' help doctors monitor patients from a distance
 Temporary tattoo that brings hospital care to the home
 
 High Reliability: 
 High reliability pediatric intensive care unit 
 OPENPediatrics - leading towards zero harm (webinar)
 OPENPediatrics - improving safety in the PICU (webinar)
 PICC 2016 - pre-congress workshops - risky business: critical care 
 RHLN - reliability leadership: examples from a paediatric intensive care unit and the riverside county EMS
 
 Learning Networks:
 CHA - PICU CLABSI collaborative
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions 
 InFACT - mapping critical care - ACCESS MAPS - project to aggregate location of acute care services worldwide
 OPENPediatrics - international web-based pediatric knowledge network - resources 
 Pediatric Intensive Care Audit Network (PICANet) - audit
 PedsCCM.org 
 PICC 2016 - pre-congress workshops
 PICC 2016 - session summaries 
 PICU Journal Watch 
 Review of pediatric critical care in resource-limited settings: a look at past, present, and future directions
 Set of quality indicators of pediatric intensive care in Spain: Delphi method selection
 Virtual Pediatric Systems (VPS) - improving critical care quality and outcomes for all children 
 WHO - critical care training short course - clinical management of patients with severe forms of influenza infection
 World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS)
 Daily Goals  Improving communication during cardiac ICU multidisciplinary rounds through visual display of patient daily goals
 Targeted interventions improve shared agreement of daily goals in the pediatric intensive care unit
 Deterioration  See 'Paediatric Early Warning System (PEWS)'
 Developing Countries and Resource-Poor Settings  See 'Child Survival in Developing Countries'
 Diagnosis  Checklists:
 
CARE approach to reducing diagnostic errors
 Checklists to reduce diagnostic errors 
 
Minimizing diagnostic error: 10 things you can do tomorrow
 SIDM - reducing diagnostic error - health care organizations - ten things I could do tomorrow
 SIDM - reducing diagnostic error - physicians, PAs, and NPs - ten things I could do tomorrow  

 Clinical Decision Support System (CDSS):
 
American College of Physicians launches ACP Smart Medicine, offering doctors 'one click to confidence'
 Can computers help doctors reduce diagnostic errors?
 Diagnostic accuracy of GPs when using an early-intervention decision support system: a high-fidelity simulation
 DXplain decision support system 
 Impact of a diagnostic decision support system on the consultation: perceptions of GPs and patients
 ISABEL - diagnostic errors 
 ISABEL Active Intelligence - diagnosis decision support system
 Learning health care system using computer-aided diagnosis
 
 Measures:
 Measures to improve diagnostic safety in clinical practice

 Medical-legal:  
 CMPA - diagnostic tips - reducing medical-legal difficulties
 Doctor's Company - diagnostic error in medical practice by specialty 
 Doctor's Company - pediatrics resources 
 Fewer medical malpractice lawsuits succeed, but payouts are up
 Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States
 Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014

 Paediatric: 
 AAP - Project RedDE!: reducing diagnostic errors in primary care pediatrics 
 Children's Colorado - reducing diagnostic errors
 Diagnostic error in children presenting with acute medical illness to a community hospital
 Diagnostic errors in the pediatric and neonatal ICU: a systematic review
 Diagnostic errors and strategies to minimize them (special issue) 
 Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study
 Errors of diagnosis in pediatric practice: a multisite survey 
 Finding diagnostic errors in children admitted to the PICU
 How doctors think: common diagnostic errors in clinical judgment - lessons from an undiagnosed and rare disease program
 Innovative collaborative model of care for undiagnosed complex medical conditions
 National physician survey of diagnostic error in paediatrics
 Overcoming diagnostic errors in medical practice
 Perspectives from a pediatrician about diagnostic errors
 PIPSQC - deciphering diagnostic errors in pediatrics 
 Why it's so easy for doctors to misdiagnose kids

 General: 
 5 ways to reduce inpatient diagnosis errors
 20 percent of patients with serious conditions are first misdiagnosed, study says
 Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care
 Addressing the problem of diagnostic errors 
 Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework 
 AHRQ - improving diagnostic safety 
 AHRQ PSNet - annual perspective 2014 - diagnostic errors 
 Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us
 Challenges and opportunities from the Agency for Healthcare Research and Quality (AHRQ) research summit on improving diagnosis: a proceedings review
 Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study
 Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed 
 Deep learning is a black box, but health care won't mind
 Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error
 Diagnosis (volume 1, issue 1)
 Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic
 Diagnostic error in medicine (special issue)
 ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis
 Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error
 Extent of diagnostic agreement among medical referrals
 Five simple steps to avoid becoming a medical mystery
 Hiding in plain sight - resurrecting the power of inspecting the patient
 Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices
 Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study
 Improving diagnosis in health care - the next imperative for patient safety
 Inpatient notes: reducing diagnostic error-a new horizon of opportunities for hospital medicine
 IOM - improving diagnosis in healthcare 
 IOM - improving diagnosis in health care: an implementation workshop
 Johns Hopkins - Center for Diagnostic Excellence
 Nearly 10 percent of strokes are misdiagnosed (at least initially) in the emergency department
 NPSF - diagnostic error prevention general resources 
 NQF - improving diagnostic accuracy project 2016-2017
 Patient safety strategies targeted at diagnostic errors: a systematic review
 Potential of collective intelligence in emergency medicine
 Preventing diagnostic errors in primary care
 Prognosis of undiagnosed chest pain: linked electronic health record cohort study
 SIDM - Coalition to Improve Diagnosis
 SIDM - diagnostic error resources 
 SIDM - diagnostic error measures worksheet
 SIDM - diagnosis and high reliability (May 2014 issue)
 SIDM - preventing diagnostic error where do I start webcast (slides) 
 System-related interventions to reduce diagnostic errors: a narrative review 
 Teaching the diagnostic process as a model to improve medical education
 Unraveling diagnostic error: delving deeply to identify hidden human factors
 Using automated surveillance to improve diagnosis
 War on error: common diagnostic errors
 Disaster Preparedness  Medical response to multisite terrorist attacks in Paris
 Simulation to predict effect of citywide events on emergency department operations
 Discharge Timeliness  Academy of Fabulous NHS Stuff - improving the time of discharge for patients
 Royal Hospital for Sick Children, Yorkhill - PICU total delayed discharges (+ 4 hrs)
 Using quality improvement to optimise paediatric discharge efficiency
 Disclosure  AHRQ - Communication and Optimal Resolution (CANDOR) toolkit 
 Applying lessons from social psychology to transform the culture of error disclosure
 Balancing doctor egos and errors
 CAPHC - talking to children about medical errors: stakeholder perspectives 
 Challenges of implementing a communication-and-resolution program where multiple organizations must cooperate
 CPSI - Canadian disclosure guidelines: being open with patients and families 
 Disclosure of adverse events in pediatrics
 Doctors could admit to mistakes without facing liability in court under proposed legislation
 Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology
 Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors
 Frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents: a systematic review
 Heart of health care: parents' perspectives on patient safety
 IHI - respectful management of serious clinical adverse events 
 Implementing an error disclosure coaching model: a multicenter case study
 Improving communication and resolution following adverse events using a patient-created simulation exercise
 Inpatient Notes: mistakes in the hospital - communicating, apologizing, and beyond
 Learning through experience: influence of formal and informal training on medical error disclosure skills in residents
 Parent preferences for medical error disclosure: a qualitative study
 Pathologists' perspectives on disclosing harmful pathology error
 PIPSQC - partnering with parents to save children's lives 
 Progress at the intersection of patient safety and medical liability (special issue)
 "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes
 Two words can soothe patients who have been harmed: we're sorry
 Disparities and Equity  Australia: 
 CareTrack Kids

 Europe:
 Dartmouth atlas of care - children's health care 
 Dartmout Institute - where children live affects care, exposing some to unnecessary treatment, imaging and medication 
 Deaths in young people aged 0-24 years in the UK compared with the EU15+ countries, 1970-2008: analysis of the WHO Mortality Database
 Improving child health services in the UK: insights from Europe and their implications for the NHS reforms 
 Mapping variation to prioritise areas needing improved outcome, quality and productivity 
 NHS - Right Care - NHS atlas of variation in healthcare for children and young adults
 PIPSQC - protecting children from harm - setting standards: a view from the UK (slides) 

 North America:
 AHRQ - national healthcare quality & disparities reports 
 Child and adolescent health care quality and disparities: are we making progress?
 Health Leads - research 
 HRET - Hospital Engagement Network (HEN) 2.0 - health care disparities
 IHI - achieving health equity: a guide for health care organizations
 IHI CEO Derek Feeley: "If there is no equity, there is no quality." (video) 
 IOM - unequal treatment: confronting racial and ethnic disparities in health care
 Duty Hours  Bipartisan consensus: the public wants well-rested medical residents to help ensure safe patient care
 Caregiver fatigue: implications for patient and staff safety - part 1 and part 2
 Common program requirements. The learning and working environment (duty hours)
 Ethical considerations in the development of the flexibility in duty hour requirements for surgical trainees trial
 Health care worker fatigue
 Latest results from the "FIRST" (Flexibility in Duty Hour Requirements for Surgical Trainees) trial 
 Medical residents angered at extended work hours
 NPSF - sleep deprivation, health care providers, and patient safety
 Patient handoffs: is cross cover or night shift better?
 Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial 
 Resident duty hours and medical education policy-raising the evidence bar
 Resident work hours and patient safety
 Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers
 Summary of proposed changes to ACGME common program requirements section VI
 Survey says: don't lift limits on residents' hours
 What is known: examining the empirical literature in resident work hours using 30 influential articles
 Work systems analysis approach to understanding fatigue in hospital nurses
 Ebola  Paediatric: 
 AAP - CDC activates Children's Task Force in response to Ebola outbreak
 AAP - Ebola outbreak 
 Being a pediatrician in an Ebola epidemic 
 Care of the child with Ebola virus disease
 CDC - Ebola resources for parents, schools, and pediatric healthcare providers 
 Ebola virus disease and children - what pediatric health care professionals need to know
 RCPCH - Ebola crisis - resources for paediatricians 
 
 General: 
 Emory Healthcare launches Ebola protocols website as resource on prevention and patient care 
 Long-term cure for Ebola: an investment in health systems
 Time person of the year - the Ebola fighters
 WHO - Ebola virus disease outbreak
 Education and Training  Paediatric: 
 CareTrack Kids - CareTrack Adverse Events Program (CAEP)
 CHA - pediatric learning solutions - online training to foundational clinical information 
 Developing future clinical leaders for quality improvement: experience from a London children's hospital 
 Equipped: introduction to quality improvement in paediatrics and child health 
 Equipped: overcoming barriers to change to improve quality of care (theories of change)
 G30 developing paediatricians as future clinical leaders: Enabling Doctors in Quality Improvement and Patient Safety (EQuIP) programme design and evaluation
 Impact of a longitudinal quality improvement and patient safety curriculum on pediatric residents
 Levine Children's - Center for Advancing Pediatric Excellence resident QI curriculum 
 Nationwide Children's - clinical fellowship in quality and safety leadership
 RCPCH - Quality Improvement and Patient Safety (QIPS) 
 Running Horse Group - EQUIPPED 
 WFPICCS - Sister PICU Program

 General:
 5 steps to better patient safety training for residents, fellows
 AHRQ PSNet - annual perspective 2014 - safety and medical education 
 Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers
 Chief of residents for quality improvement and patient safety: a recipe for a new role in graduate medical education
 CPME - key findings and recommendations on education and training in patient safety across Europe
 CUGH - Annotated List of Online Global Health Resources
 Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences
 Growth mindset approach to preparing trainees for medical error
 IHI Open School - online courses in patient safety and improvement capability 
 Improving engagement with patient safety through educational events
 Making residents part of the safety culture: improving error reporting and reducing harms
 National report of findings 2016: issue brief No. 2: patient safety
 New graduate registered nurses' knowledge of patient safety and practice: a literature review
 NHS - e-learning for healthcare 
 NHS England - Q Initiative
 NPSF - patient safety curriculum 
 Partnerships, capacity building needed to strengthen universities in developing nations
 Patient Safety Education Program - Canada (PSEP - Canada) 
 Patient safety and interprofessional education: a report of key issues from two interprofessional workshops
 Quality and Safety Education for Nurses (QSEN) - QSEN competencies
 Quality and safety in nursing: a competency approach to improving outcomes, second edition
 WHO - critical care training short course - clinical management of patients with severe forms of influenza infection
 WHO - multi-professional patient safety curriculum guide 
 eHealth, mHealth, and Telehealth  CAPHC - Pocket Doc for Pneumonia: top 10 Google.org impact challenge finalist
 Children's Hospital of Pittsburgh (CHP) - telemedicine program
 Commonwealth Fund - mobile health and patient engagement in the safety net: a survey of community health centers and clinics 
 Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU
 OPENPediatrics - leading towards zero harm (webinar)
 OPENPediatrics - improving safety in the PICU (webinar)
 OPENPediatrics - Pediatric Clinical Safety Investigation (CSI) - virtual patient safety rounds (#1-8) (webinars) 
 Saving lives from afar: bridging the knowledge (& distance) gaps in health care with the cloud
 Telehealth in the developing world: current status and future prospects 
 UHN - Centre for Global eHealth Innovation
 WHO - 7 day mother baby mCheck tool
 WHO - Global Observatory for eHealth 
 WHO - impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?
 WHO - launch of mHealth toolkit to help innovators scale up projects for reproductive, maternal, newborn, child and adolescent health
 Eliminating Preventable Harm  Building a high-reliability organization: one system's patient safety journey
 Children's Hospitals' Solutions for Patient Safety (SPS)
 Health care learning networks: widespread effort to eliminate medical errors among kids
 Improving safety for pediatric patients
 OHMCH celebrates 365 days without a serious safety event
 NPSF - making quality and safety a priority in health care for our children
 SickKids - Caring Safely 
 UHN - Caring Safely (slides) 
 UHN - renewing UHN - Caring Safely
 UHN - update UHN plans for 2016: Caring Safely
 Emergency Care  AAP - joint policy statement - guidelines for care of children in the emergency department 
 Adverse event and error of unexpected life-threatening events within 24h of emergency department admission
 Ask Me to Explain Campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department
 Bias in the ER. Doctors suffer from the same cognitive distortions as the rest of us
 CHA - strategies to better serve the emergency department population
 Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic
 Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments
 Early death after discharge from emergency departments: analysis of national US insurance claims data
 ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis
 Emergency Medical Services for Children (EMSC) - National Resource Center - toolboxes 
 Emergency room doctors may impact patients' opioid use
 Ethics in the pediatric emergency department: when mistakes happen: an approach to the process, evaluation, and response to medical errors
 ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients
 Identifying high-risk children in the emergency department 
 Identifying and reducing complications after emergency room discharge
 Impact of telemedicine on severity of illness and outcomes among children transferred from referring emergency departments to a children's hospital PICU
 Implementation of the WHO Trauma Care Checklist Program in 11 centers across multiple economic strata: effect on care process measures
 In situ simulation: detection of safety threats and teamwork training in a high risk emergency department
 Meds IQ - emergency drug dose calculator
 Monash Children's - pediatric emergency medication book
 National assessment of pediatric readiness of emergency departments 
 National Pediatric Readiness Project (Peds Ready) - ensuring emergency care for all children
 National Pediatric Readiness Project (Peds Ready) - readiness toolkit 
 Nearly 10 percent of strokes are misdiagnosed (at least initially) in the emergency department
 Opioid-prescribing patterns of emergency physicians and risk of long-term use
 Patient safety in the emergency department
 PIPSQC - keeping kids safe during critical illness and resuscitation 
 Potential of collective intelligence in emergency medicine
 Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score
 Scoring systems in paediatric emergency care: Panacea or paper exercise?
 Simulation for operational readiness in a new freestanding emergency department: strategy and tactics
 Simulation to predict effect of citywide events on emergency department operations
 TREKK - ED clinical pathways implementation
 TREKK -translating emergency knowledge for kids 
 Using automated surveillance to improve diagnosis 
 WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline
 Emergency Medical Services (EMS)  Center for Patient Safety - EMS patient safety boot camp
 Elimination of emergency department medication errors due to estimated weights
 Emergency Medical Services for Children (EMSC) - National Resource Center - toolboxes
 Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study
 Patient safety events in out-of-hospital paediatric airway management: a medical record review by the CSI-EMS
 Pediatric patient safety in emergency medical services
 Pediatric prehospital medication dosing errors: a mixed-methods study 
 Pediatric prehospital medication dosing errors: a national survey of paramedics
 PIPSQC - keeping kids safe during critical illness and resuscitation
 Systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics
 Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review
 Employee Safety  Addressing physician burnout: the way forward 
 AHRQ PSNet - annual perspective 2015 - burnout among health professionals and its effect on patient safety
 Amazing way this hospital is fighting physician burnout - Code Lavender program
 Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses
 Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections
 Can we talk about physician mental health
 Caregiver fatigue: implications for patient and staff safety - part 1 and part 2 
 Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment
 Center for Patient Safety - second victim experience
 CHA - reducing employee burnout key to improving quality and safety in health care
 CHA - strategies for helping employees stay healthy on the job
 CHA - strategies for supporting employees' mental health 
 Children's Hospitals' Solutions for Patient Safety (SPS) taps Value Capture to expand its life-saving efforts
 Cincinnati Children's - reduce employee injury 
 Clinician support: five years of lessons learned
 Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis
 Cost-benefit analysis of a support program for nursing staff
 Design of an evidence-based "second victim" curriculum for nurse anesthetists
 Despite burnout, there's still joy in medicine
 Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout
 Doctors, hospitals prepare for difficult talks surrounding medical mistakes
 Effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism
 Ensuring staff safety when treating potentially violent patients
 Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout
 Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach
 From shame to guilt to love 
 Growth mindset approach to preparing trainees for medical error
 Healthcare staff wellbeing, burnout, and patient safety: a systematic review 
 How to prevent burnout (maybe)
 IHI - building a clinician peer support program
 Implementation of a 'second victim' program in a pediatric hospital 
 Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study
 Incivility, bullying, and workplace violence
 International children's hospitals' patient safety effort that is saving lives is expanding efforts to employee/staff safety
 International conference on physician health - 2016 presentations
 IOM - Action Collaborative on Clinician Well-Being and Resilience
 IOM - National Academy of Medicine launches 'Action Collaborative' to promote clinician well-being and combat burnout, depression, and suicide among health care workers
 Joint Commission - improving patient and worker safety - opportunities for synergy, collaboration and innovation 
 Joint Commission - interview with Paul O'Neill
 Making it Safer Together (MiST) - caring for the carers   
 Mayo Clinic - executive leadership and physician well-being. Nine organizational strategies to promote engagement and reduce burnout
 Medical error: the second victim
 MedStar Health HRO phase II: care for the caregiver
 MedStar Health - quality and patient safety videos - care for the caregiver programs
 Nationwide Children's - best outcomes in action: YOU Matter second victim program 
 Nationwide Children's - Nationwide Children's hospital participating in international children's hospitals' patient safety effort that is saving lives and expanding efforts to employee/staff safety
 NPSF - just culture as a foundation for joy in work: the impact of leaders
 NPSF - three organizational strategies to reduce burnout and build engagement in health care
 NPSF - through the eyes of the workforce: creating joy, meaning, and safer health care 
 NPSF - overlap between organizational contributions to burnout and workplace violence... is there overlap of solutions?
 Official critical care societies collaborative statement: burnout syndrome in critical care health care professionals: a call for action
 On the relationship between safety climate and occupational burnout in healthcare organizations
 Organizational framework to reduce professional burnout and bring back joy in practice
 OSHA worker safety in hospitals - caring for our caregivers 
 Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses
 Patient safety improves when providers feel psychologically safe 
 Patient safety and workplace bullying: an integrative review
 Paul O'Neill on protecting our healthcare workforce #NPSFLLI7
 Paula Davis Laack - burnout 
 Peer Support for Clinicians: A Programmatic Approach
 Physician burnout is a public health crisis: a message to our fellow health care CEOs
 Piece of my mind. Speak up
 PIPSQC - who guards the guardians? 
 Price of incivility
 Promoting safety through well-being: an experience in healthcare
 Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis
 Psychological responses, coping and supporting needs of healthcare professionals as second victims
 Quadruple Aim: care of the provider 
 Qualitative study about the experiences of colleagues of health professionals involved in an adverse event
 Quotes from the Paul O'Neill podcast interview on patient safety
 Relationship between professional burnout and quality and safety in healthcare: a meta-analysis
 Respect: the foundation for quality care 
 Rude providers jeopardize patient safety. So stop it
 Rudeness and medical team performance
 Scott three-tiered interventional model of second victim support
 Second victim: a review
 Surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study
 Triple Aim must turn into the Quadruple Aim. here’s why.
 Value Capture - opportunity: identifying and eliminating worker injuries
 Virginia Mason - respect for people: a building block for engaged staff, satisfied patients 
 Unprofessional workplace conduct... defining and defusing it
 Why healthcare organizations must embrace the 'Quadruple Aim'
 Work systems analysis approach to understanding fatigue in hospital nurses
 Workplace factors associated with burnout of family physicians
 Flow  Health Foundation - challenge and potential of whole system flow - improving the flow of people, information and resources across whole health and social care economies
 General/Community Hospitals  See 'Adult Hospitals and the Care of Children'
 Global Child Health  See 'Child Survival in Developing Countries'
 Haematology/Oncology  2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology
 Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015)
 CHA - Childhood Cancer & Blood Disorders Network
 CHA - for this children's hospital CEO, the fight against pediatric cancer is personal
 Chemotherapy safety standards: A pediatric perspective
 Evaluation of electronic health record implementation on pharmacist interventions related to oral chemotherapy management
 Impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy
 Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital
 Improving physician's hand over among oncology staff using standardized communication tool
 Interventions to improve oral chemotherapy safety and quality: a systematic review
 Just Bag It - NCCN campaign for safe Vincristine handling
 Making it Safer Together (MiST) - paediatric patient safety collaborative - haematology/oncology 
 Performance of a trigger tool for identifying adverse events in oncology
 PIPSQC - unique patient safety challenges of children with cancer 
 Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: A time series analysis
 Significant and sustained reduction in chemotherapy errors through improvement science
 Singularity University - Dr. Daniel Kraft
 WHO - early cancer diagnosis saves lives, cuts treatment costs
 Hand Hygiene  AHA - HPOE - Children's Hospital Colorado - reliable hand hygiene 
 Butterfly effect of hand hygiene on antibiotic resistance 
 CDC - clean hands count
 CDC - hand hygiene in healthcare settings
 Clean Hands Save Lives 
 CPSI - STOP! Clean Your Hands Day - tools and resources
 Effectiveness of a hospital-wide programme to improve compliance with hand hygiene
 Electronic hand-hygiene monitoring cuts MRSA rates by nearly half
 Hand washing stops infections, so why do health care workers skip it?
 How hospital workers solve patient-safety problems on their own
 Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance
 iScrub Lite
 Tell me how pleased you are with your workplace, and I will tell you how often you wash your hands
 WHO - Clean Care is Safer Care 
 WHO hand-hygiene compliance strategy easy for health-care workers to practice 
 WHO - patient safety - Geneva University Hospital
 WHO - save lives: clean your hands
 Handoffs and Communication  As a critical behavior to improve quality and patient safety in health care: speaking up!
 Association between end-of-rotation resident transition in care and mortality among hospitalized patients
 Birmingham Children's - improving handovers in paediatric care (slides)
 Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care
 Challenging the status quo: focusing on patient safety and joy at work
 Changes in medical errors after implementation of a handoff program
 Conflict in a paediatric hospital: a prospective mixed-method study
 Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic
 Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis
 Half-life of a printed handoff document 
 Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture
 Handoffs: transitions of care for children in the emergency department
 Health Foundation - Safer Clinical Systems: Birmingham Children's Hospital 
 High-reliability and the I-PASS communication tool
 Implementation of a modified bedside handoff for a postpartum unit
 Improving patient safety in handover from intensive care unit to general ward: a systematic review
 Improving physician's hand over among oncology staff using standardized communication tool
 Improving resident handoffs for children transitioning from the intensive care unit
 Information handoff and outcomes of critically ill patients transferred between hospitals
 Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program
 Introducing a new junior doctor electronic weekend handover on an orthopaedic ward
 I-PASS Handoff Study 
 I-PASS, a mnemonic to standardize verbal handoffs
 Joint Commission - improving communication, reducing medical errors
 Joint Commission - Transitions of Care (ToC) portal
 Large-scale implementation of the I-PASS handover system at an academic medical centre
 Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes
 Model to support staff in raising their concerns
 Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment
 Nervecentre Software - clinical applications for mobile technology - clinical noting and ehandover
 New horizons in patient safety: understanding communication: case studies for physicians
 Paperless handover: are we ready? 
 Patient Hand-Off iNitiation and Evaluation (PHONE) study: a randomized trial of patient handoff methods
 Patient handoffs: is cross cover or night shift better?
 PCORI - bringing I-PASS to the bedside: a communication bundle to improve patient safety and experience 
 Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program
 PIPSQC - I-PASS in critical care 
 Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study
 QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings
 Quality of handoffs in community pharmacies
 Quality improvement approach to standardization and sustainability of the hand-off process
 Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle
 SaferHealthcare - Situation, Background, Assessment and Recommendation (SBAR) 
 SickKids - shift-change handoff program recognized for improving patient safety through standardization of provider-to-provider communication
 Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents
 Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies
 Standardization of inpatient handoff communication
 Standardization of postoperative transitions of care to the pediatric intensive care unit enhances efficiency and handover comprehensiveness
 Supporting quality improvement in paediatrics across an entire healthcare system
 Variation in printed handoff documents: results and recommendations from a multicenter needs assessment
 Year-end resident clinic handoffs: narrative review and recommendations for improvement
 Health IT  Paediatric: 
 AHRQ - children's electronic health record (EHR) format 
 CHA - 6 ways children's hospitals are using mobile apps 
 CHA - 25 biggest pediatric health care innovations in 25 years
 CHA - commentary: supplement health care technology with human interaction and communication
 Computerized provider order entry and patient safety
 Evaluating serial strategies for preventing wrong-patient orders in the NICU
 How medical tech gave a patient a massive overdose 
 Innovative use of the electronic health record to support harm reduction efforts
 Leapfrog - pediatric CPOE evaluation tool 
 National trends in safety performance of electronic health record systems in children's hospitals Restricted access
 Pediatric hospitals show wide gap in EHR safety performance
 Quality of care and information technology (special issue)
 Use of a health information exchange system in the emergency care of children
 Use of patient pictures and verification screens to reduce computerized provider order entry errors

 General: 
 All CLEAR? Preparing for IT downtime
 Are informed policies in place to promote safe and usable EHRs? A cross-industry comparison
 Benefits of health information technology: a review of the recent literature shows predominantly positive results
 Characterizing the source of text in electronic health record progress notes
 Checking the lists: a systematic review of electronic checklist use in health care
 COACH - esafety guidelines: landmark patient safety resource 
 Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors
 Datix patient safety software
 Design and testing of the safety agenda mobile app for managing health care managers' patient safety responsibilities
 Digital doctor: hope, hype, and harm at the dawn of medicine's computer age 
 E-collection: safety and error prevention in health
 ECRI Institute - the partnership for health IT patient safety
 Effects of health information technology on patient outcomes: a systematic review
 Emerging from EHR purgatory - moving from process to outcomes
 Examining the copy and paste function in the use of electronic health records
 FDA - Computerized Prescriber Order Entry Medication Safety (CPOEMS)
 Health IT Safety Centre Roadmap
 HealthIT.gov - SAFER guides  
 Health Level 7 (HL7) International - standards
 How to improve electronic health record usability and patient safety
 IHI - WIHI: digital transformation: how technology is helping (and hurting) health care
 Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis
 Impact of electronic medical records on hospital-acquired adverse safety events: differential effects between single-source and multiple-source systems
 Implications of electronic health record downtime: an analysis of patient safety event reports
 IOM - health IT and patient safety: building better systems for safer care
 IT's role in improving patient safety - where do we stand?
 Joint Commission - safe health IT saves lives
 Meaningful use of health information technology and declines in in-hospital adverse drug events
 National survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites
 NHS - the integrated digital care technology fund 
 NPSF - organizational best practices for optimizing health IT safety
 ONC offers recommendations for safe, effective health IT use
 Pew analysis: despite ONC's EHR oversight, patient safety issues persist 
 Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review
 Rising frequency of IT blackouts indicates the increasing relevance of IT emergency concepts to ensure patient safety
 Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration
 Safety huddles to proactively identify and address electronic health record safety
 Study: clinicians copy and paste about half of text in EHR progress notes
 Towards a framework for managing risk associated with technology-induced error
 Unintended consequences of health IT: new problems and new solutions           
 Vulnerabilities of computerized physician order entry systems: a qualitative study
 Health Literacy  CDC - clear communication index
 CDC - learn about health literacy
 Communicating clearly about medicines: proceedings of a workshop - in brief
 IOM - health literacy: past, present, and future: workshop summary 
 Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency
 NPSF - Ask Me 3: good questions for your good health
 NPSF - health literacy
 Pennsylvania Patient Safety Authority - health literacy and patient safety events
 Pennsylvania Patient Safety Authority - health literacy oral communication skills for clinicians
 Preventing vital health care information from being lost in translation
 Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites
 High Reliability and HROs  Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice
 AHRQ PSNet - primers - high reliability
 Aiming higher to enhance professionalism - beyond accreditation and certification
 Applying the high reliability health care maturity model to assess hospital performance: a VA case study
 Are hospitals really serious about patient safety? 6 things we can learn from other industries
 Ascension Health - establishing a culture of high reliability (page 20)
 Ascension Health - high reliability organizations healing without harm by 2014 (slides)
 Building a high-reliability organization: one system's patient safety journey
 Building the road to high reliability
 Children's Hospitals' Solutions for Patient Safety (SPS) - network design & process 
 Comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality 
 Cooperative high reliability organization: approaching a zero-defect culture
 Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine
 Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals
 Eliminating patient harm - in embracing the concept of high reliability, hospitals work to stamp out patient harm
 Eliminating preventable harm to patients and staff
 Five lessons healthcare leaders are learning from an unlikely source: nuclear power
 Five system barriers to achieving ultrasafe health care
 HealthCare Reliability Organizing (HCRO) - about us 
 Health Foundation - high reliability organisations
 Health Foundation - using safety cases in industry and healthcare
 Healthcare Performance Improvement (HPI)
 High-reliability health care: getting there from here
 High reliability helps Connecticut hospital reduce safety errors by 80 percent 
 High-reliability and the I-PASS communication tool
 High reliability organizations finding a home in Canada
 High reliability organizations: a healthcare handbook for patient safety & quality
 High Reliability Organizing (HRO) 
 High reliability pediatric intensive care unit 
 High reliability: what's the role of the patient, family, public, and community?
 HQI - HealthCare Reliability Organizing (HCRO)            
 IHI - framework for safe, reliable, and effective care 
 IHI - highly reliable hospitals: the work ahead 
 IHI - reliable systems and processes
 IHI - stop wasting time on 100 percent reliability 
 IHI: this way to patient safety
 Imperial College London - safer healthcare - approaches to safety: one size does not fit all
 Imperial College London - transforming patient safety: a sector-wide systems approach
 Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers
 International prize in resilient health care
 Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition
 Joint Commission - model differentiates hospitals' high reliability maturity levels
 Joint Commission - safety culture and high reliability: stages of organizational maturity
 Joint Commission Center for Transforming Healthcare - high reliability 
 Joint Commission Center for Transforming Healthcare - high reliability - resources
 Joint Commission Center for Transforming Healthcare - Michigan is the second state to partner with the Joint Commission center for transforming healthcare on a statewide high reliability improvement effort
 Leading high-reliability organizations in healthcare 
 Long and winding road toward greater quality and safety - Memorial Hermann and Virginia Mason health systems make big leaps in improving patient safety
 MedStar Health - quality and patient safety - quality & safety videos - an introduction to HRO tools
 MedStar Health - safety across the board: integrating just culture, high reliability and open, honest communication
 More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?
 Next wave of hospital innovation to make patients safer
 NPSF - reliability at the sharp end of care
 Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement
 Organizational behavior: a brief overview and safety orientation
 Organizational learning framework for patient safety
 PICC 2016 - risky business: critical care - learning from high risk industries to improve quality and safety
 Re-examining high reliability: actively organising for safety
 Reliability engineering & system safety - resilience engineering (special issue)
 Resilient health care, volume 3: reconciling work-as-imagined and work-as-done
 RHLN - reliability leadership: examples from a paediatric intensive care unit and the riverside county EMS 
 SaferHealthcare - high reliability topics 
 Safety perceptions of health care leaders in 2 Canadian academic acute care centers
 Safety and reliability in pediatrics (special issue) 
 Stories clinicians tell: achieving high reliability and improving patient safety
 Towards high-reliability organising in healthcare: a strategy for building organisational capacity
 UHN - Renewing UHN - Caring Safely
 Hospital Acquired Conditions (HACs):

 - ADE
 - CAUTI
 - CLABSI 
 - Falls
 - OB-AE 
 - PIVIE
 - PU
 - SSI 
 - Unplanned Extubations
 - VAP
 - VTE
 CLABSI:
 Alder Hey Children's - introduction of a specialist paediatric vascular access team in an acute trust (slides)
 CHA - Childhood Cancer & Blood Disorders Network - CLABSI prevention for ambulatory patients
 CHA - PICU CLABSI collaborative
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & CLABSI webinars 
 Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis 
 Fifteen years after To Err is Human: a success story to learn from
 Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial 
 Incorporating quality and safety values into a CLABSI simulation experience
 Making it Safer Together (MiST) - vascular access 
 PICC 2016 - how to secure and maintain intravenous access in the PICU 
 Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: A time series analysis
 Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-Year analysis
 Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections
 Unbundling the bundles: using apparent and systemic cause analysis to prevent health care-associated infection in pediatric intensive care units
 Zero tolerance for deadly hospital-acquired infections

 Paediatric: 
 AHA - Children's Colorado and Nationwide Children's quality and safety journey (slides)
 Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections
 CEC - pediatric quality program
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions 
 Children's National - reducing harm: impact of unplanned extubations (pages 10-14)
 Children's spin-off company eKare wins Washington Business Journal 2106 Innovation Award
 Impact of a pressure injury prevention bundle in the Solutions for Patient Safety Network
 Innovative use of the electronic health record to support harm reduction efforts
 Making it Safer Together (MiST) - paediatric patient safety collaborative - safety themes
 NHS - Children and Young People's Services (C&YPS) NHS Safety Thermometer 
 NINJA system aims to reduce acute kidney injury in hospitalized kids nationwide
 OPENPediatrics - leading towards zero harm (webinar)
 Scottish Patient Safety Programme (SPSP) - Maternity & Children Quality Improvement Collaborative (MCQIC)
 Surgical site infection reduction by the solutions for patient safety hospital engagement network
 Sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury
 Unbundling the bundles: using apparent and systemic cause analysis to prevent health care–associated infection in pediatric intensive care units
 
 General: 
 AHRQ - Comprehensive Unit-based Safety Program (CUSP) 
 AHRQ - funding announcement for projects targeting the reduction of healthcare-associated infections
 AHRQ - healthcare-associated infections program 
 AHRQ - patient safety measure tools & resources - patient safety tools & resources
 AHRQ - toolkit to reduce CAUTI and other HAIs in long-term care facilities
 Ambient Clinical Analytics - syndromic surveillance - ventilator-induced lung injury sniffer (VILI sniffer)
 American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update
 ANA - CAUTI prevention tool
 CDC - healthcare associated infections 
 CEC - patient safety programs
 Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017
 CIHI - 1 in 18 patients experiences harm in Canadian hospitals - hospital harm project FAQ
 CIHI - hospital harm project
 CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm
 CMS - Partnership for Patients (PfP) - Hospital Improvement Innovation Networks (HIINs)
 CMS - Partnership for Patients (PfP) - resources 
 Commonwealth Fund - hospitals in rapid-paced quality improvement 
 Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes
 Danish Safer Hospital Programme packages 
 Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative
 HRET - Hospital Engagement Network (HEN) 2.0 - Partnership for Patients (PfP) education series  
 HRET - Hospital Engagement Network (HEN) 2.0 - topics 
 Hybrid methodology for modeling risk of adverse events in complex health-care settings
 Intentional rounding: a staff-led quality improvement intervention in the prevention of patient falls
 Joint Commission Center for Transforming Healthcare - targeted initiatives
 Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals
 Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System
 Medicare failed to investigate suspicious infection cases from 96 hospitals
 MRSA rates dropped 87% in VA hospital ICUs
 Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
 National implementation project to prevent catheter-associated urinary tract infection in nursing home residents
 NDNQI - pressure ulcer survey guide
 NHS - NHS Safety Thermometer
 PaSQ - patient safety and quality of care good practices 
 Patient engagement with surgical site infection prevention: an expert panel perspective
 Patient Safety Movement - challenges & solutions 
 Preventing patient falls: a systematic approach from the Joint Commission Center for Transforming Healthcare project
 Proactive risk assessment of surgical site infections in ambulatory surgery centers
 SHEA - compendium of strategies to prevent healthcare-associated infections in acute care hospitals 
 Systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes 
 Tension between promoting mobility and preventing falls in the hospital
 Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events
 UHN - Caring Safely (slides) 
 Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls
 Viewing Prevention of Catheter-Associated Urinary Tract Infection as a System: Using Systems Engineering and Human Factors Engineering in a Quality Improvement Project in an Academic Medical Center
 WHO - global guidelines on the prevention of surgical site infection
 WHO guidelines take aim at surgical infections, superbugs
 WHO - patient safety - implementing change
  
 Note: 
 Hospital Acquired Conditions (HACs) include: 
 adverse drug events (ADE); catheter-associated urinary tract infections (CAUTI); central line-associated blood stream infections (CLABSI); injuries from falls and immobility; obstetrical adverse events (OB-AE); peripheral intravenous infiltration and extravasations (PIVIE); pressure ulcers (PU); surgical site infections (SSI); unplanned extubations; ventilator-associated pneumonia (VAP); venous thromboembolism (VTE); and more.
 Hospital Acquired Infections (HAIs)  See 'Hospital Acquired Conditions (HACs)'
 Hospital at Night (HaN)  Birmingham Children's - improving handovers in paediatric care (slides)
 Nervecentre Software - clinical applications for mobile technology - Hospital at Night (HaN)
 Hospital Design  Bad hospital design is making us sicker
 Healthier Hospitals Initiative (HHI)
 Huddles  See 'Situation Awareness'
 Human Factors  5 thoughts from an Eisenberg Patient Safety and Quality Award winner
 A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong
 AHRQ - making health care safer II: an updated critical analysis of the evidence for patient safety practices - chapter 31: human factors and ergonomics
 AHRQ - mistake-proofing the design of healthcare processes 
 AHRQ PSNet - human factors engineering
 Applying human-centered design thinking to enhance safety in the OR
 Atrainability - human factors training for safe and effective teams
 Bad hospital design is making us sicker
 CHFG - 'how to' guide to human factors - top tips
 CHFG - resources
 CHFG - top 10 health technology hazards - ECRI institute
 CHFG - 'what good looks like' prompt cards - from a human factors perspective
 CPQI - patient safety - SEIPS tools
 CPQI - Systems Engineering Initiative for Patient Safety (SEIPS) 
 Defining the role of social sciences in patient safety online (special issue) 
 Dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation
 ECRI Institute - top 10 health technology hazards for 2017
 ECRI out with 10 deadly healthcare technology hazards for 2017
 FDA - applying human factors and usability engineering to medical devices - February 19, 2016
 Handbook of human factors and ergonomics in health care and patient safety, second edition
 Health Foundation - safer care: human factors for healthcare 
 Healthcare Human Factors - projects
 Healthcare Human Factors - target zero for patient safety 
 Healthcare Human Factors - work 
 Human factors and ergonomics in manufacturing & service industries: patient safety (special issue) 
 Human factors and ergonomics as a patient safety practice
 Human factors and ergonomics in practice - improving system performance and wellbeing in the real world
 Human Factors and Ergonomics Society (HFES) - health care symposia 
 Human Factors and Ergonomics Society (HFES) - health care technical group of HFES
 Human factors-focused reporting system for improving care quality and safety in hospital wards 
 Human factors in healthcare: welcome progress, but still scratching the surface
 Human factors science: brief history and applications to healthcare 
 HumanEra - projects 
 Humanistic systems
 Improving infusion pump safety through usability testing
 Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature
 Inpatient notes: human factors engineering and inpatient care - new ways to solve old problems
 Interview with Pascale Carayon
 Joint Commission Big Book of Checklists
 MedStar Health - human factors and patient safety
 MedStar Health - safety across the board: integrating just culture, high reliability and open, honest communication
 More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?
 National Center for Human Factors Engineering in Health Care - research
 New focus on hospital errors aims to correct problems
 Operational failures detected by frontline acute care nurses
 Patient safety: the role of human factors and systems engineering 
 PIPSQC - systems thinking and the paediatric provider (slides)
 Resilient health care, volume 3: reconciling work-as-imagined and work-as-done
 Safety differently - Steven Shorrock
 Safety differently: human factors for a new era
 Sidney Dekker - safety differently - talks
 Systems Engineering Initiative for Patient Safety (SEIPS) - short course
 Utilizing a human factors nursing worksystem improvement framework to increase nurses' time at the bedside and enhance safety
 WHO - patient safety - human factors tools
 Work systems analysis approach to understanding fatigue in hospital nurses
 Journals  AHRQ PSNet - pediatrics 
 CHA - Children's Hospitals Today - patient safety
 CHA - Children's Hospitals Today - quality improvement
 Current Treatment Options in Pediatrics - topical collection on patient safety
 Pediatric Clinics of North America - quality of care and information technology
 Pediatric Clinics of North America - safety and reliability in pediatrics
 Pediatric Quality & Safety (PQS)
 Quality and Safety in Health Care (special issue)
 Junior Doctors  Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment
 CHA - pediatric learning solutions - online training to foundational clinical information 
 Chief of residents for quality improvement and patient safety: a recipe for a new role in graduate medical education
 DAPS (Doctors Advancing Patient Safety) Global 
 Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis
 Dr. Toolbox - collaborative local knowledge resource for professional healthcare communities 
 Growth mindset approach to preparing trainees for medical error
 IHI Open School - online courses in patient safety and improvement capability
 Increasing resident autonomy without compromising patient safety
 Is the "July Effect" real? Pediatric trainee reported medical errors and adverse events
 Making residents part of the safety culture: improving error reporting and reducing harms
 Resident physicians' clinical training and error rate: the roles of autonomy, consultation, and familiarity with the literature 
 'See one, sim one, do one' - a national pre-internship boot-camp to ensure a safer 'student to doctor' transition
 You can't blame the wreck on the train
 Leadership  Boards can be safety champions - trustees play a critical role in overseeing patient safety
 Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers
 Center for Patient Safety - leadership, louder than words: C-suite ambassadors of patient safety
 Closing the gap and raising the bar: assessing board competency in quality and safety
 Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine
 Do hospital boards matter for better, safer, patient care?
 CMS - Partnership for Patients (PfP) - leadership 
 How much should hospital trustees know about patient safety?
 Joint Commission - essential role of leadership in developing a safety culture
 Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition
 Knowing, and doing: closing the gaps in board leadership for improvement of quality and safety
 NHS Improvement - developing people - improving care - a national framework for action on improvement and leadership development in NHS-funded services
 NPSF - leading a culture of safety: a blueprint for success
 Patient safety efforts need engaged leaders
 Patient safety and leadership: do you walk the walk?
 PIPSQC - leadership and preoccupation with failure
 Safety perceptions of health care leaders in 2 Canadian academic acute care centers
 WHO - global experts’ consultation for the development of the leaders’ guide
 Malpractice  2% of physicians accountable for half of malpractice reports
 Association between state medical malpractice environment and postoperative outcomes in the United States
 Association of unsolicited patient observations with the quality of a surgeon's care
 CMPA - diagnostic tips - reducing medical-legal difficulties
 Detection, analysis, and significance of physician clustering in medical malpractice lawsuit payouts
 Doctor's Company - pediatrics resources
 Doctors could admit to mistakes without facing liability in court under proposed legislation
 Fewer medical malpractice lawsuits succeed, but payouts are up
 Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis
 HPOE - progress at the intersection of patient safety and medical liability
 Impact of medical errors and malpractice on health economics, quality, and patient safety
 Medical diagnoses commonly associated with pediatric malpractice lawsuits in the United States
 Medical Malpractice Center - pediatric malpractice
 NPSF - patient complaints and post-operative complications
 Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014
 Relationship between state malpractice environment and quality of health care in the United States
 Two words can soothe patients who have been harmed: we're sorry
 Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications
 Medical Devices  AAP - safe and effective drugs and medical devices for children
 CAPHC - implementing the ENFit standards: preparing for the impact on clinical practice
 ECRI Institute - browse topics
 ECRI Institute - top 10 health technology hazards for 2017
 Emergency department visits for medical device-associated adverse events among children 
 FDA - applying human factors and usability engineering to medical devices - February 19, 2016
 FDA - pediatric medical devices
 FDA - reducing risks associated with medical device misconnections
 FDA working to ensure the safety of medical devices used in the pediatric population 
 Implementing smart infusion pumps with dose-error reduction software: real-world experiences
 Improper device cleaning may be leading to infections or broken devices
 Improving infusion pump safety through usability testing
 ISMP - ENFit enteral devices are on their way... Important safety considerations for hospitals
 Making it Safer Together (MiST) - safety alert: is ENFit safe for small children & neonates?
 Mind the gap & why 'Ruby's Rule' won't work
 National Pediatric Readiness Project (Peds Ready) - guidelines for equipment, supplies, and medications for the care of pediatric patients in the ED 
 NHS England - preventing medical device incidents
 IOM - safe medical devices for children
 Pediatric devices and adverse events from a to z: understanding the benefits and risks from a US FDA perspective 
 Premier - tubing misconnections - resources
 Prevalence and nature of adverse medical device events in hospitalized children 
 "We can't get along without each other": qualitative interviews with physicians about device industry representatives, conflict of interest and patient safety
 Medical Emergency Team (MET)  See 'Rapid Response Team (RRT)'
 Medical Errors  See 'Adverse Event Detection'
 Medication Safety  Assessment:

 CEC - Medication Safety Self Assessment Program (MSSA)

 Bar Code Medication Administration (BCMA):
 Comparison of medication safety systems in critical access hospitals: combined analysis of two studies
 Creating a culture of safety around bar-code medication administration: an evidence-based evaluation framework
 Effect of barcode-assisted medication administration on emergency department medication errors
 Effects of bar-coding technology on medication errors: a systematic literature review
 Effect of the implementation of barcode technology and an electronic medication administration record on adverse drug events
 Improved supply chain in Canadian health system can save lives
 NPSF - medication barcode optimization
 OhioHealth improves patient safety with processes and advanced technologies
 Pediatric medication administration errors and workflow following implementation of a bar code medication administration system
 WIN - visibility: the new value proposition for health systems (slides)
 WIN - visibility: the new value proposition for health systems - executive summary

 Computerized Physician Order Entry (CPOE):
 AHRQ - children's electronic health record (EHR) format
 Analysis of variations in the display of drug names in computerized prescriber-order-entry systems
 Assessing frequency and risk of weight entry errors in pediatrics
 Automated detection of look-alike/sound-alike medication errors
 Bainbridge Health - makes infusion pump management easier and "smarter"
 CHA - saving lives and reducing medication errors with data
 Clinical decision support for drug related events: moving towards better prevention
 Clinical reasoning in the context of active decision support during medication prescribing
 CPOE and patient safety
 CPOE-related patient safety reports: analysis of 2522 medication errors
 Digital doctor: hope, hype, and harm at the dawn of medicine's computer age
 ECRI Institute - the partnership for health IT patient safety
 EHR-related medication errors in two ICUs
 Electronically generated medication administration and electronic medication administration records for the prevention of medication transcription errors: review of clinical effectiveness and safety
 Evaluating serial strategies for preventing wrong-patient orders in the NICU
 Evaluation of medication-related clinical decision support alert overrides in the intensive care unit
 Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study
 FDA - Computerized Prescriber Order Entry Medication Safety (CPOEMS)
 Health IT Safety Center Roadmap
 HealthIT.gov - SAFER guides
 High-priority drug-drug interactions for use in EHRs
 Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis
 Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture
 Incorporating indications into medication ordering - time to enter the age of reason
 Joint Commission - safe health IT saves lives
 Leapfrog - pediatric CPOE evaluation tool
 Learning from errors: analysis of medication order voiding in CPOE systems
 Looking for safety insights in medication order changes
 Medication safety in two intensive care units of a community teaching hospital after electronic health record implementation: sociotechnical and human factors engineering considerations
 National trends in safety performance of EHR systems in children's hospitals
 ONC offers recommendations for safe, effective health IT use
 Optimization of drug-drug interaction alert rules in a pediatric hospital's EHR using a visual analytics dashboard
 Ordering interruptions in a tertiary care center: a prospective observational study
 Pablo Garcia case study (full story): How medical tech gave a patient a massive overdose
 Pablo Garcia case study (Part 5): How to make hospital tech much, much safer - We identified the root causes of Pablo Garcia's 39-fold overdose?- and ways to avoid them next time
 Pediatric hospitals show wide gap in EHR safety performance
 Pennsylvania Patient Safety Authority - medication errors attributed to health information technology
 Prescription errors related to the use of computerized provider order-entry system for pediatric patients
 Responsible e-prescribing needs e-discontinuation
 Screen flashes and pop-up reminders: 'alert fatigue' spreads through medicine
 Screening for medication errors using an outlier detection system
 Systematic review of the types and causes of prescribing errors generated from using CPOE systems in primary and secondary care
 Use of patient pictures and verification screens to reduce CPOE errors
 Vulnerabilities of CPOE systems: a qualitative study

 Emergency Medications:
 Decreasing prescribing errors during pediatric emergencies: a randomized simulation trial
 Medication errors in the management of anaphylaxis in a pediatric emergency department
 Meds IQ - emergency bolus and infusion calculators - New Zealand
 Meds IQ - emergency drug dose calculator  
 Monash Children's - pediatric emergency medication book
 National Pediatric Readiness Project (Peds Ready) - guidelines for equipment, supplies, and medications for the care of pediatric patients in the ED
 National Pediatric Readiness Project (Peds Ready) - key points on medication errors
 Pediatric Emergency Medication Book - book review
 Pediatric prehospital medication dosing errors: a mixed-methods study
 Pediatric prehospital medication dosing errors: a national survey of paramedics
 PIPSQC - keeping kids safe during resuscitation and critical illness
 Quality improvement intervention reduces the time to administration of stat medications

 Errors - Inpatient:
 Alarming reality of medication error: a patient case and review of Pennsylvania and national data
 Economic impact of medication error: a systematic review
 Elimination of emergency department medication errors due to estimated weights
 Medication safety in neonatal care: a review of medication errors among neonates
 PA Patient Safety Advisory - Medication errors affecting pediatric patients: unique challenges for this special population
 Sick children face potentially deadly danger: medication errors
 Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital

 Errors - Outpatient:
 All consumer medication information is not created equal: implications for medication safety
 Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database
 Carers' medication administration errors in the domiciliary setting: a systematic review
 CDC - PROTECT initiative: advancing children's medication safety
 CDC - UpandAway.org
 Communicating clearly about medicines: proceedings of a workshop - in brief
 Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions
 Economic impact of medication error: a systematic review
 Fate of pediatric prescriptions in community pharmacies
 Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency
 Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit
 Medication errors in outpatient pediatrics
 Misuse of pediatric medications and parent-physician communication: an interactive voice response intervention
 Out-of-hospital medication errors among young children in the United States, 2002-2012
 Patient-centered prescription drug label to promote appropriate medication use and adherence
 Pediatric adverse drug events in the outpatient setting: an 11-year national analysis
 US emergency department visits for outpatient adverse drug events, 2013–2014 

 High-Alert Drugs:
 2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology
 Association of medication errors with drug classifications, clinical units, and consequence of errors: are they related?
 Automated detection of look-alike/sound-alike medication errors
 Best practices for chemotherapy administration in pediatric oncology: quality and safety process improvements (2015) 
 Challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations
 Chemotherapy safety standards: a pediatric perspective
 Evaluating the potential severity of look-alike, sound-alike drug substitution errors in children
 ISMP - ISMP updates its list of drug names with tall man letters
 Just Bag It - NCCN campaign for safe Vincristine handling
 Medication errors associated with transition from insulin pens to insulin vials
 New safety risks detected in one-third of FDA-approved drugs
 PA Patient Safety Authority - analysis of reported drug interactions: a recipe for harm to patients
 Preventing high-alert medication errors in hospital patients
 Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care
 Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet
 Significant and sustained reduction in chemotherapy errors through improvement science
'Smart pills' help doctors monitor patients from a distance

 Huddle:
 Meds IQ - DRUG-gle (Druggle) - medication-focused safety 'huddle'

 Medication Administration:  
 Differentiating between detrimental and beneficial interruptions: a mixed-methods study 
 Double checking the administration of medicines: what is the evidence? a systematic review
 Drug administration errors in hospital inpatients: a systematic review
 Comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study
 Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study
 Electronically generated medication administration and electronic medication administration records for the prevention of medication transcription errors: review of clinical effectiveness and safety
 Implementing a distraction-free practice with the Red Zone Medication Safety Initiative
 Interruption handling strategies during paediatric medication administration
 Interruptions and medication administration in critical care
 Interventions to reduce nurses' medication administration errors in inpatient settings: a systematic review and meta-analysis
 Meds IQ - new content on Meds IQ launching this autumn - medicines administration!
 Meds IQ - safe treatment and administration of medicines in paediatrics (STAMP)
 Meds IQ - safe treatment and administration of medicines in paediatrics (STAMP) - webinar recording
 Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting
 NPSF - National Patient Safety Foundation DAISY award for extraordinary nurses 2017 honorees announced
 Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices
 Nursing interruptions in a trauma intensive care unit: a prospective observational study
 Patients at risk from 'nested interruptions' in nursing tasks, human factors paper reports
 Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode
 Qualitative, exploratory study of nurses' decision-making when interrupted during medication administration within the paediatric intensive care unit
 Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era
 Relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study
 Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting
 Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study
 Teaching students to administer medications safely
 Traditions of research into interruptions in healthcare: a conceptual review
 Two sides to every story: the Dual Perspectives Method for examining interruptions in healthcare
 Using human factors design principles and industrial engineering methods to improve accuracy and speed of drug selection with medication trays
 Utilizing a human factors nursing worksystem improvement framework to increase nurses' time at the bedside and enhance safety

 Medication Reconciliation (MedRec):
 Beyond medication reconciliation: the correct medication list
 CPSI - 5 questions to ask about your medications
 Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?
 Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge
 High 5s initiative: implementation of medication reconciliation in France a 5 years experimentation
 Holland Bloorview - implementation of medication reconciliation in a pediatric ambulatory care setting (slides)
 Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review electronically prepopulated medication reconciliation forms may actually adversely impact medication safety
 Insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs
 Measuring to improve medication reconciliation in a large subspecialty outpatient practice
 Medication reconciliation failures in children and young adults with chronic disease during intensive and intermediate care
 Medication reconciliation process and classification of discrepancies: a systematic review
 Medication reconciliation: the role of the pharmacy technician
 MediStori - paper based personal health organizer
 Meds IQ - medicines reconciliation in children
 Nurse-pharmacist collaboration on medication reconciliation prevents potential harm
 Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis
 PSQH - medication reconciliation: improve compliance across healthcare settings
 SHM - MARQUIS - medication reconciliation implementation toolkit
 Value of the pharmacist in the medication reconciliation process
 WHO - High 5s Project  - medication reconciliation implementation guide

 Operating Room Medications:
 Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study
 Medication safety in the operating room: literature and expert-based recommendations

 Opioids:
 APSF - monitoring for opioid-induced ventilatory impairment (OIVI)
 Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis
 CAPHC - June 12 ministerial opioid roundtable
 CAPHC - paediatric opioid safety resource kit
 CHA - rate of toddlers hospitalized from opioid poisoning on the rise
 Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015
 FDA - safe use initiative
 Guideline for opioid therapy and chronic noncancer pain
 Human factors approach to evaluating intravenous morphine administration in a paediatric surgical unit
 iDoseCheck - morphine double check
 iDoseCheck - preventing wrong dose morphine errors - testing the iDoseCheck: a tool to enhance inter-professional communication and care planning (slides)
 Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score?
 ISMP - a national collaborative: advancing medication safety in paediatrics
 NPSF - surveillance monitoring for all
 Opioid medication errors in pediatric practice: four years' experience of voluntary safety reporting
 Opioid prescribing and potential overdose errors among children 0 to 36 months old
 Overdose risk in young children of women prescribed opioids
 Potential acetaminophen and opioid overdoses in young children prescribed combination acetaminophen/opioid preparations
 PPAHS - 5 keys to reducing harms from opioids: Physician-Patient Alliance for Health & Safety releases podcast with ECRI Institute
 PPAHS - opioid safety
 PPAHS - patients on opioids should be monitored for respiratory compromise 24×7
 Prescription opioid exposures among children and adolescents in the United States: 2000-2015
 Prescriptions may hold clues to who gets hooked on opioids, study says
 SIDM - opioid crisis: can improving diagnosis help solve the problem?
 Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analgesia in a UK paediatric hospital
 Studies raise questions about why young mothers are being prescribed opioids
 Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015  

 Pharmacists:
 ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education - 2015
 Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study
 Could it be done safely? Pharmacists views on safety and clinical outcomes from the introduction of an advanced role for technicians
 Death due to pharmacy compounding error reinforces need for safety focus
 Do the math: time for pharmacists in the ED
 Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis
 Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study)
 Medication safety systems and the important role of pharmacists
 Pharmacy automation system PillPick helps hospitals eliminate medication errors
 Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance

 Prescribing:
 Analysis of medication prescribing errors in critically ill children
 Assessing frequency and risk of weight entry errors in pediatrics
 Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review
 Effect of prescriber education on medication-related patient harm in the hospital: a systematic review
 Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study
 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective
 Is an indication-based prescribing system in our future?
 ISMP - despite technology, verbal orders persist, read back is not widespread, and errors continue
 Making it Safer Together (MiST) - electronic prescribing and administration
 Meds IQ - Paediatric SCRIPT - safe and effective prescribing for children
 Ordering interruptions in a tertiary care center: a prospective observational study
 PA Patient Safety Advisory - prescribing errors that cause harm
 PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique
 Prescription errors related to the use of computerized provider order-entry system for pediatric patients
 Proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation
 Reducing adverse drug events - the need to rethink outpatient prescribing
 Responsible e-prescribing needs e-discontinuation

 Priority Areas:
 CDC - PROTECT initiative: advancing children's medication safety
 CEC - Medication Safety Self Assessment Program (MSSA)
 Children's Hospitals' Solutions for Patient Safety (SPS) - recommended bundles - adverse drug events (ADE)
 CMS - Partnership for Patients (PfP) - adverse drug event priority areas for pediatric patients (slides)
 CMS - Partnership for Patients (PfP) - adverse drug event priority areas for pediatric patients (notes)
 CMS - Partnership for Patients (PfP) - Dale Ann Micalizzi - an uphill climb leading to patient safety
 IOM - safe and effective medicines for children
 Interventions to reduce pediatric medication errors: a systematic review
 ISMP - getting closer to the bull’s eye: 2014-2015 targeted medication safety best practices (follow-up survey results)
 ISMP - a national collaborative: advancing medication safety in paediatrics
 ISMP - results of survey on pediatric medication (part 1)
 ISMP - results of survey on pediatric medication (part 2)
 ISMP - survey on implementation of the 2016-2017 targeted medication safety best practices for hospitals
 ISMP - two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes
 Medication governance: preventing errors and promoting patient safety
 Medication safety in the neonatal intensive care unit: big measures for our smallest patients
 Meds IQ - sharing QI resources for paediatric medication safety
 Meds IQ - champions network
 Patient Safety Movement - challenges & solutions - pediatric adverse drug events
 Pediatric medication safety in adult community hospital settings: a glimpse into nationwide practice
 PIPSQC - from innovation to dissemination: Meds IQ, a new platform for paediatric medicines safety QI
 Prevention of medication errors in the pediatric inpatient setting
 Report of the announced inspection of medication safety at the Midland Regional Hospital Tullamore, County Offaly
 SPS - adverse drug event (ADE) prevention roadmap
 Three simple rules to improve medication safety
 WHO - medication without harm: WHO's third global patient safety challenge
 WHO - WHO global patient safety challenge - medication safety
 WHO - WHO launches global effort to halve medication-related errors in 5 years 

 Reporting:
 Adverse drug event reporting systems: a systematic review
 Learning from the design, development and implementation of the Medication Safety Thermometer
 National Coordinating Council for Medication Error Reporting and Prevention creates an analysis tool for adverse drug events
 National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
 NHS Safety Thermometer - medication safety thermometer

 Smart Infusion Pumps:
 Accidents and incidents related to intravenous drug administration: a pre-post study following implementation of smart pumps in a teaching hospital
 Bainbridge Health - makes infusion pump management easier and "smarter"
 CHA - saving lives and reducing medication errors with data
 Changing smart pump vendors: lessons learned
 Dangerous infusion errors top ECRI Institute's annual health technology hazards list
 Frequency of intravenous medication administration errors related to smart infusion pumps: a multihospital observational study
 Implementing smart infusion pumps with dose-error reduction software: real-world experiences
 Improving infusion pump safety through usability testing
 Infusion medication error reduction by two-person verification: a quality improvement initiative
 Role of 'smart' infusion pumps in patient safety

 Standardisation - Infusions:
 ASHP - IV adult continuous infusions
 ASHP - Standardize 4 Safety - first national effort to standardize medication concentrations
 Making it Safer Together (MiST) - infusion standardization - September 2016 update
 Medication errors involving the intravenous administration route: characteristics of voluntarily reported medication errors
 Meds IQ - infusion standardisation
 NSW Health - standards for paediatric IV fluids: NSW Health (2nd edition)
 Risk factors for i.v. compounding errors when using an automated workflow management system
 Royal Children's - paediatric injectable guidelines
 Safe implementation of standard concentration infusions in paediatric intensive care
 Standard concentration infusions in paediatric intensive care: the clinical approach
 Standardize 4 Safety initiative releases final IV recommendations for medication safety 
 Standardizing concentrations of adult drug infusions in Indiana

 Standardisation - Oral Liquids:
 FDA - Safe Use Initiative - unintentional medication overdoses in children
 Liquid medication errors and dosing tools: a randomized controlled experiment
 Michigan Pediatric Safety Collaboration to Standardize Compounded Oral Liquids
 Standardization of compounded oral liquids for pediatric patients in Michigan

 Tubing Misconnections:
 AAP - safe and effective drugs and medical devices for children 
 ASPEN safe practices for enteral nutrition therapy
 CAPHC - implementing the ENFit standards: preparing for the impact on clinical practice
 FDA - pediatric medical devices
 FDA - reducing risks associated with medical device misconnections
 FDA working to ensure the safety of medical devices used in the pediatric population
 ISMP - accidental IV infusion of heparinized irrigation in the OR
 ISMP - ENFit enteral devices are on their way... Important safety considerations for hospitals
 Making it Safer Together (MiST) - safety alert: is ENFit safe for small children & neonates?
 Mind the gap & why 'Ruby's Rule' won't work
 Pediatric devices and adverse events from a to z: understanding the benefits and risks from a US FDA perspective
 Premier - tubing misconnections - resources
 Prevalence and nature of adverse medical device events in hospitalized children

 Global:
 Institute for Safe Medication Practices (ISMP)
 International Medication Safety Network (IMSN)
 Medication safety for children in China
 Medication Safety Officers Society (MSOS) 
 WHO - essential medicines for children - publications 
 WHO - medication without harm: WHO's third global patient safety challenge
 WHO - WHO global patient safety challenge - medication safety 

 Mental Health  CAPHC - addressing the adolescent depression challenge
 Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences
 Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports
 MindEd 
 Pediatric and adolescent mental health emergencies in the emergency medical services system 
 Scottish Patient Safety Programme (SPSP) - mental health
 Teenmentalhealth.org
 Mislabeled Specimens  Blood bank safety practices - mislabeled samples and wrong blood in tube - a Q-Probes analysis of 122 clinical laboratories
 Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions
 Dichotomy of the application of a systems approach in UK healthcare the challenges and priorities for implementation
 Final Check - reason for a 90+% reduction in the number of mislabeled blood specimens
 Getting it right for patient safety: specimen collection process improvement from operating room to pathology
 Managing the patient identification crisis in healthcare and laboratory medicine
 Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study
 Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module
 Surgical specimen management: a descriptive study of 648 adverse events and near misses
 Morbidty and Mortality (M&M) Rounds  CPS - standardization of child & youth death review
 Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study
 Envisioning the future morbidity and mortality conference: a vehicle for systems change
 Implementation of a structured hospital-wide morbidity and mortality rounds model
 Investigating avoidable patient deaths
 Learning, candour and accountability. A review of the way NHS trusts review and investigate the deaths of patients in England
 Medical morbidity and mortality conferences: past, present and future
 Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement
 Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?
 New programme aims to standardise hospital death reviews
 Processes for identifying and reviewing adverse events and near misses at an academic medical center
 Role of morbidity and mortality rounds in medical education: a scoping review
 Quality gaps identified through mortality review
 Standardization of case reviews (morbidity and mortality rounds) promotes patient safety
 National Patient Safety Board  CHFG - healthcare safety investigation branch - expert advisory group report
 CHFG - learning from failure: the need for independent safety investigation in healthcare
 Healthcare needs an NTSB-like agency
 National patient safety board necessary to prevent patient deaths
 NTSB for health care: learning from innovation: debate and innovate or capitulate 
 Patient-safety advocates issue call for regulation
 Patient safety advocates urge the creation of a national patient safety board to fight medical errors 
 Patient safety leaders propose ‘NTSB for healthcare’
 Why congress needs to create a national patient safety board 
 Would an NTSB approach succeed in healthcare?
 Neonatal Intensive Care Unit (NICU)  See 'Neonatal-Perinatal'
 Neonatal-Perinatal  BAPM - Newborn Early Warning Trigger and Track (NEWTT) 
 'Busy day' effect on perinatal complications of delivery on weekends
 Canadian Neonatal Network (CNN)
 CAPHC - CIHR-IHDCYH's preterm birth initiative: investing in preterm birth and perinatal health care research
 Case for quality improvement in the neonatal intensive care unit 
 CDC - perinatal quality collaboratives 
 CHA - strategies to care for babies born drug dependent
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles & operational definitions 
 Comparing NICU teamwork and safety climate across two commonly used survey instruments
 Decreasing malpractice claims by reducing preventable perinatal harm
 How communication among members of the health care team affects maternal morbidity and mortality
 IHI - Perinatal Improvement Community 
 Implementation of a modified bedside handoff for a postpartum unit
 Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback
 Is communication improved with the implementation of an obstetrical version of the World Health Organization safe surgery checklist?
 Last person you'd expect to die in childbirth
 Medication errors by caregivers at home in neonates discharged from the neonatal intensive care unit
 Medication safety in neonatal care: a review of medication errors among neonates
 Medication safety in the neonatal intensive care unit: big measures for our smallest patients
 National Perinatal Information Center - quality improvement/patient safety 
 NHS England - Saving Babies' Lives Care Bundle
 NICHQ - Collaborative Improvement and Innovation Network (COIIN) to Reduce Infant Mortality 
 NPSF - reducing MRSA infections in the neonatal ICU
 Ohio Perinatal Quality Collaborative 
 Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative
 Premier Perinatal Safety Initiative 
 Progress at the intersection of patient safety and medical liability (special issue)
 RCOG - Each Baby Counts 
 Safety interventions on the labor and delivery unit
 Second Victim: a review
 Temporary tattoo that brings hospital care to the home
 Tools and methods for quality improvement and patient safety in perinatal care
 Transforming maternity care - maternal and perinatal care quality collaboratives 
 UCSF - Preterm Birth Initiative (PTBi)
 Vermont Oxford Network (VON) - improving care for infants and their families 
 WHO - Collaborating Center for Training and Research in Newborn Care
 Never Events  See 'Sentinel Events'
 Opioids  2017 Canadian guidelines for opioids for chronic non cancer pain
 Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs
 APSF - monitoring for opioid-induced ventilatory impairment (OIVI)
 Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis
 CAPHC - June 12 ministerial opioid roundtable
 CAPHC - paediatric opioid safety resource kit 
 CHA - rate of toddlers hospitalized from opioid poisoning on the rise
 CHA - strategies to care for babies born drug dependent
 Characteristics of initial prescription episodes and likelihood of long-term opioid use - United States, 2006-2015
 Declines in opioid prescribing after a private insurer policy change - Massachusetts, 2011 - 2015
 Development and applications of the Veterans health administration's stratification tool for opioid risk mitigation (STORM) to improve opioid safety and prevent overdose and suicide
 Emergency room doctors may impact patients' opioid use
 Ending the opioid epidemic - a call to action
 FDA - safe use initiative 
 Guideline for opioid therapy and chronic noncancer pain
 Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration
 Human factors approach to evaluating intravenous morphine administration in a paediatric surgical unit
 iDoseCheck - morphine double check
 iDoseCheck - preventing pediatric medication errors - testing the iDoseCheck
 iDoseCheck - preventing wrong dose morphine errors - testing the iDoseCheck: a tool to enhance inter-professional communication and care planning (slides)
 Impact of the opioid safety initiative on opioid-related prescribing in veterans
 Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score?
 ISMP - a national collaborative: advancing medication safety in paediatrics 
 Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates
 Medication sharing, storage, and disposal practices for opioid medications among US adults
 National Action Plan for Adverse Drug Event Prevention: recommendations for safer outpatient opioid use
 National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012
 New persistent opioid use after minor and major surgical procedures in US adults
 NPSF - surveillance monitoring for all
 Opioid medication errors in pediatric practice: four years’ experience of voluntary safety reporting
 Opioid overdoses among kids, teens have nearly tripled in recent years
 Opioid-prescribing patterns of emergency physicians and risk of long-term use
 Opioid prescribing and potential overdose errors among children 0 to 36 months old 
 Opioid-related inpatient stays and emergency department visits by state, 2009-2014
 Opioids for pain management in older adults: strategies for safe prescribing
 Overdose risk in young children of women prescribed opioids
 Pain management and prescription opioid-related harms: exploring the state of the evidence: proceedings of a workshop - in brief
 Physicians take steps to address opioid overdose epidemic
 Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey
 Potential acetaminophen and opioid overdoses in young children prescribed combination acetaminophen/opioid preparations
 PPAHS - 5 Keys to Reducing Harms from Opioids: Physician-Patient Alliance for Health & Safety Releases Podcast with ECRI Institute
 PPAHS - opioid safety
 PPAHS - patients on opioids should be monitored for respiratory compromise 24×7 
 Predictors of in-hospital postoperative opioid overdose after major elective operations: a nationally representative cohort study
 Prescription drug monitoring programs: evidence-based practices to optimize prescriber use  
 Prescription opioid exposures among children and adolescents in the United States: 2000-2015
 Prescriptions may hold clues to who gets hooked on opioids, study says
 SIDM - opioid crisis: can improving diagnosis help solve the problem?
 Sources and magnitude of error in preparing morphine infusions for nurse-patient controlled analgesia in a UK paediatric hospital 
 Studies raise questions about why young mothers are being prescribed opioids
 Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976-2015
 Turn the Tide Rx - surgeon general's call to end opioid crisis
 U of T - safe opioid prescribing skills webinar series
 US Department of Veterans Affairs - VHA pain management - opioid safety initiative (OSI)
 Paediatric Early Warning System (PEWS)  Electronic: 
 
Birmingham Children's - RAPID (Real-Time Adaptive and Predictive Indicator of Deterioration)
 Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children
 Impact of introducing an electronic physiological surveillance system on hospital mortality 
 Nervecentre Software - clinical applications for mobile technology - electronic observations (e-PEWS) 
 Nervecentre Software - top 5 reasons trusts chose Nervecentre for electronic observations
 NHS England - electronic PEWS 
 NHS England - integrated digital care record - success story: safer hospitals, safer wards technology fund (Nottingham University Hospitals) 
 NUH - Using mobile technology to transform communication and safety - electronic 'eObservations and eHandover'
 Real-time risk prediction on the wards: a feasibility study

 Emergency Department: 
 
CHA - 20 second sepsis screen (slides)
 Identifying high-risk children in the emergency department
 Scoring systems in paediatric emergency care: panacea or paper exercise?

 Australia: 
 ACSQHC - observation charts for paediatric and maternity settings 
 ACSQHC - recognising and responding to clinical deterioration - guide to implementation of the national consensus statement
 'Between the flags': implementing a rapid response system at scale
 CEC - Pediatric Quality Program - Between the Flags (BtF) 
 Children's Hospital at Westmead - lessons from medical emergency teams in Australia (slides) 
 Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis
 Improving the recognition of, and response to in-hospital sepsis 
 Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios
 Royal Children's - escalation of care flowchart 
 Royal Children's - Victorian Children's Tool for Observation and Response (ViCTOR)
 Victorian Children's Tool for Observation and Response (ViCTOR)

 Europe: 
 BAPM - Newborn Early Warning Trigger and Track (NEWTT)
 HSE - Irish Paediatric Early Warning System (PEWS) 
 ICNARC - National Cardiac Arrest Audit (NCAA): in-hospital cardiac arrests for paediatric patients
 MiST - paediatric early warning systems (PEWS) 
 NCEC national clinical guidelines - clinical deterioration - paediatric early warning system (PEWS)
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer - deterioration
 NHS England - exploring a national paediatric early warning system (PEWS) 
 NHS England - PEWS charts
 NHS England - Respond to Ailing Child Tool (Re-ACT) 
 NUH - Recognise and Rescue: a hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals NHS Trust
 NUH - Recognise and Rescue - improving the care of the deteriorating pediatric patient
 NUH - Recognise and Rescue praised by NHS England leaders 
 NUH - Recognise and Rescue programme: improving patient safety
 Nurses' 'worry' as predictor of deteriorating surgical ward patients: a prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score
 Optimizing patient safety for paediatric patients in 5 Dutch general hospitals by introducing PEWS within an (inter)national exchange collaborative network
 Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review
 Paediatric Early Warning Systems: myths and muses
 PaSQ - paediatric early warning scores (PEWS) 
 PIPSQC - don't just stand there - #REACT! REACT - the Respond to Ailing Children Tool 
 PIPSQC - Irish Paediatric Early Warning System (PEWS)
 RCPCH - safe system framework for children at risk of deterioration
 RCPCH - Situation Awareness for Everyone (S.A.F.E)
 Spotting the Sick Child 
 SPSP - paediatric care - paediatric early warning score (PEWS) charts
 SPSP - paediatric care - Paediatric Sepsis 6
 SPSP - paediatric care - PEWS as a system
 SPSP - paediatric care - PEWS as a system - webex
 Supporting quality improvement in paediatrics across an entire healthcare system
 Systematic literature review to support the development of a national clinical guideline - paediatric early warning system (PEWS) 
 UK Sepsis Trust - clinical toolkits - acute hospital-inpatients 
 Validation of National Early Warning Score in the prehospital setting
 What impact did a paediatric early warning system have on emergency admissions to the paediatric intensive care unit? an observational cohort study 

 North America:
 Bedside Clinical Systems (BCS) - BedsidePEWS - news
 Bedside Clinical Systems (BCS) - BedsidePEWS - product 
 Cincinnati Children's - emergency codes outside the ICU
 Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: root cause analysis of unplanned ICU admissions
 Errors, omissions, and outliers in hourly vital signs measurements in intensive care
 Evaluating processes of care and outcomes of children in hospital (EPOCH): study protocol for a randomized controlled trial 
 Finding patients before they crash: the next major opportunity to improve patient safety 
 Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events
 Model can ID patients at risk for serious safety events
 Multicenter collaborative approach to reducing pediatric codes outside the ICU
 NPSF - surveillance monitoring for all
 Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides)

 South America: 
 Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital
 Paediatric Intensive Care Unit (PICU)  See 'Critical Care'
 Pain  CAPHC - acute procedural pain: paediatric recommendations and implementation toolkits
 CAPHC - paediatric pain
 CAPHC - practice change: it doesn't have to be painful!
 Centre for Pediatric Pain Research - resources for health professionals 
 Clinical recommendations for pain, sedation, withdrawal and delirium assessment in critically ill infants and children: an ESPNIC position statement for healthcare professionals
 It Doesn't Have to Hurt - proven pain control for children 
 Neonatal pain: what's age got to do with it?  
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer 
 Pain in hospitalized children: effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes
 SickKids - pain centre
 Systematic review of the effects of repeated painful procedures in infants: is there a potential to mitigate future pain responsivity?
 Patient and Family Engagement  Bedside Nursing Handover:
 
AHRQ - nurse bedside shift report 
 AHRQ Health Care Innovations Exchange - standardized shift-change process optimizes time for transfer of patient care responsibility, leads to high levels of nurse and patient satisfaction 
 CHA - partnering with children and families to achieve bedside nursing shift-handover
 Cincinnati Children's - increasing patient satisfaction by moving nursing shift report to the bedside 
 Nurse Knowledge Exchange Plus: human-centered implementation for spread and sustainability
 PCORI - bringing I-PASS to the bedside: a communication bundle to improve patient safety and experience 
 SickKids - partnering with children and families to achieve bedside nursing shift-handover (slides)
 
 Family Activated RRT:
 CHEO - CHEO's SPOT Team and Patient Safety Ambassadors program
 Developing and evaluating the success of a family activated medical emergency team: a quality improvement report 
 Family initiated escalation of care for the deteriorating patient in hospital: Family centred care or just "box ticking"
 Impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review
 Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review
 Josie King Foundation - Condition Help (Condition H) 
 Queensland Health - Ryan's Rule - consumer/family escalation process
 
 Family-Centered Rounds:  
 Cincinnati Children's - implementing patient- and family-centered rounds  
 Family-centered rounds checklist, family engagement, and patient safety: a randomized trial
 PIPSQC - ward rounds: ideas for making them better

 Reporting:
 
Barriers and facilitators of adverse event reporting by adolescent patients and their families
 BC Children's - establishing a pediatric family-initiated safety reporting program (slides)
 BC Children's - patient's view: seeing safety through the eyes of families at BC Children’s Hospital 
 BC Children's - what a family perspective teaches about adverse events in the pediatric setting (slides) 
 Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention
 Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report
 Families as partners in hospital error and adverse event surveillance
 Implementation and evaluation of a prototype consumer reporting system for patient safety events
 Parent-reported errors and adverse events in hospitalized children 
 Patient feedback reporting tool for OpenNotes: implications for patient–clinician safety and quality partnerships
 Patient reported approach to identify medical errors and improve patient safety in the emergency department
 Patient reporting and action for a safe environment (PRASE) intervention: a feasibility study
 PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety
 Using an inpatient portal to engage families in pediatric hospital care

 Shared Decision Making:
 
Citizens for Patient Safety - shared decision making 
 Doctor's Company - are decisions shared?
 IHI/NPSF - webcast: shared decision making and patient safety: making the connections

 Paediatric: 
 Ask Me to Explain Campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department
 But I told you she was ill! the role of families in preventing avoidable harm in children 
 CAPHC - 'Passport' helps parents plan move from hospital to home
 CHA - discussing quality with patients and families
 Children's Hospitals' Solutions for Patient Safety (SPS) - 2016 patient safety awareness week materials
 EngagingPatients.org - patient and family reporting: new knowledge, new advances
 Improving safety: engaging with patients and families makes a difference!
 Joint Commission - Speak Up: prevent errors in your child's care
 Justin's HOPE - Pediatric Safety Project
 Listen to parents of sick children rather than tests, NHS tells doctors
 NHS England - Respond to Ailing Child Tool (Re-ACT)
 Parents' perspectives on "keeping their children safe" in the hospital
 Partnering with parents and families to provide safer care: seeing and achieving safer care through the lens of patients and families
 Piece of my mind. After the medical error
 PIPSQC - protecting children from harm in pediatrics: lessons learned from parents (slides) 
 RCPCH - safe system framework for children at risk of deterioration
 RCPCH - Situation Awareness for Everyone (S.A.F.E) - Royal Free Hospital parent and patient engagement poster 
 SickKids - advancing child and family-centered care at SickKids: grounded by an organizational assessment (slides) 
 SickKids - building the connection for patient safety: engaging the patient and changing the organization (slides)

 General: 
 
ACSQHC - National Safety and Quality Health Service (NSQHS) Standard 2: partnering with consumers
 AHRQ - guide to improving patient safety in primary care settings by engaging patients and families
 AHRQ - guide to patient and family engagement in hospital quality and safety 
 Care 2 Collaborate - Advancing Partnerships in Care 
 CPSI - patient engagement resources
 CPSI - SHIFT to Safety
 Engagingpatients.org - best practices
 Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction
 Feeling unsafe in the healthcare setting: patients' perspectives
 HRET - a leadership resource for patient and family engagement strategies
 HRET - Hospital Engagement Network (HEN) 2.0 - patient and family engagement
 IHI - Always Events framework 
 Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm
 IPFCC - Leveraging the principles of high reliability to advance patient and family engagement in safety
 MHA Keystone - advancing patient- and family-centered care in Michigan - a road map to patient and family engagement
 Nine ways to avoid self-care mistakes
 NPSF - united for patient safety - resources
 Patient safety: a public health crisis for a nation of patients
 Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study
 Roadmap for patient and family engagement in healthcare practice and research 
 ThinkSAFE - patient safety support for patients, families and carers
 Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites
 WHO - exploring patient participation in reducing health care related safety risks 
 WHO - framework on integrated people-centred health services
 WHO - Patients for Patient Safety (PFPS) - feature projects - WHO global framework on patient and family engagement
 Patient Identification  CHIME unveils national patient identifier challenge finalists
 Evaluating serial strategies for preventing wrong-patient orders in the NICU
 Joint Commission - patient identification
 Managing the patient identification crisis in healthcare and laboratory medicine
 PIPSQC - two patient identifiers and patient safety: a case of mistaken identity 
 Preventable, potentially fatal patient identification errors analyzed by ECRI Institute Patient Safety Organization (PSO)
 Reduction in pediatric identification band errors: a quality collaborative
 When doctors get the wrong patient
 Patient Safety Indicators (PSIs)  Australia:
 
CareTrack Kids - part 1. assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development

 Europe: 
 
ISD Scotland - care quality indicators - specialist children's services
 ISD Scotland - other information on child health
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer
 NHS - Hospital Episode Statistics - inpatient, outpatient, and A&E records
 Set of quality indicators of pediatric intensive care in Spain: Delphi method selection
 
 North America: 
 AAP - pediatric clinical quality measures to be part of meaningful use program in 2014  
 AHRQ - chartbook on patient safety
 AHRQ - measuring patient safety events: opportunities and challenges
 AHRQ - national quality measures clearing house - measure matrix
 AHRQ - new system aims to improve patient safety monitoring
 AHRQ - Pediatric Quality Indicators (PDIs) 
 AHRQ - pediatric toolkit for using the AHRQ quality indicators
 AHRQ - quality indicators
 AHRQ - quality measure tools & resources - child health care quality toolbox 
 AHRQ - quality and safety review system
 AHRQ PSNet - America's hospitals: improving quality and safety - the joint commission's annual report 2015
 Associations between hospital characteristics, measure reporting, and the Centers for Medicare & Medicaid Services overall hospital quality star ratings
 Assumptions of quality medicine: the role of uncertainty
 Building a highway to quality health care
 CAPHC - measurement to action - the Hospital Harm Indicator
 CHA - developing new pediatric quality measures 
 CIHI - 1 in 18 patients experiences harm in Canadian hospitals
 CIHI - hospital harm project
 CMS validated hospital inpatient quality reporting program data, but should use additional tools to identify gaming
 CMS - 2014 Clinical Quality Measures (CQM) - pediatric recommended core set table 
 Complication rates, hospital size, and bias in the CMS Hospital-Acquired Condition Reduction Program
 Concerns about using the Patient Safety Indicator-90 composite in pay-for-performance programs
 CPSI - hospital harm measure
 Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine
 Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data
 Developing measures for pediatric quality: methods and experiences of the CHIPRA pediatric quality measures program grantees 
 Dissecting Leapfrog: how well do Leapfrog Safe Practices Scores correlate with Hospital Compare ratings and penalties, and how much do they matter?
 Doing well by doing good: evaluating the influence of patient safety performance on hospital financial outcomes
 Effect of a real-time pediatric ICU safety bundle dashboard on quality improvement measures 
 Fostering transparency in outcomes, quality, safety, and costs
 From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system
 Hospital Safety Grade
 Hospital Safety Grade - lives lost and lives saved
 HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program
 IOM - vital signs: core metrics for health and health care progress
 Impact of Medicare's nonpayment program on hospital-acquired conditions
 Importance of the pediatric quality measurement program in advancing children’s health care: a view from children’s hospitals 
 Innovative use of the electronic health record to support harm reduction efforts
 Investigating adverse event free admissions in medicare inpatients as a patient safety indicator
 Is preventable harm the right patient safety metric? 
 Joint Commission - America's hospitals: improving quality and safety - The Joint Commission's annual report 2016
 Leapfrog gives a third of U.S. hospitals an 'A' for safety
 Leapfrog hospital safety score, Magnet designation, and healthcare-associated infections in United States hospitals
 Leapfrog hospital survey
 Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future)
 Measurement as a performance driver: the case for a national measurement system to improve patient safety
 Medicare failed to investigate suspicious infection cases from 96 hospitals
 Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
 New CMS hospital quality star ratings: the stars are not aligned
 NHS - NHS Safety Thermometer
 NQF - patient safety project 2015-2017
 NQF - pediatric measures 
 OPENPediatrics - update on pediatric index of mortality
 Predictors of gaps in patient safety and quality in U.S. hospitals
 Preventable Harm Index: an effective motivator to facilitate the drive to zero 
 Secret data on hospital inspections may soon become public
 Self-reported quality measures don't add up, study says
 UHC - Safety Intelligence (powered by Datix)
 Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
 Patient Safety Priority Areas  Paediatric:  
 Adverse events among children in Canadian hospitals: the Canadian paediatric adverse events study
 AHRQ - patient safety in the context of perinatal, neonatal, and pediatric care (grant)
 Building a culture of safety in pediatrics and child health
 Can a quality improvement project impact maternal and child health outcomes at scale in northern Ghana?
 CareTrack Kids - part 3. adverse events in children's healthcare in Australia: study protocol for a retrospective medical record review
 CEC - pediatric quality program
 Children's Hospitals' Solutions for Patient Safety (SPS) - Children's Hospitals' Solutions for Patient Safety selected to continue improvements in patient safety (2016)
 Children's Hospitals' Solutions for Patient Safety (SPS) - our focus 
 CPSI -  Canadian Paediatric Adverse Events Study (CPAES)
 Ending Preventable Child and Maternal Deaths - A Promise Renewed (APR) - resources
 Health care learning networks: widespread effort to eliminate medical errors among kids
 Improving safety for pediatric patients
 International Pediatric Association (IPA) - Quality of Care (QoC)
 Making it Safer Together (MiST) paediatric patient safety collaborative - safety themes
 Moving the needle in children's health with national collaborative networks - a CEO's perspective
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer
 NHS - review of patient safety for children and young people
 NHS England - Sign Up to Safety: children and young people’s patient safety expert group 
 NPSF - making quality and safety a priority in health care for our children
 Ohio Children's Hospitals' Solutions for Patient Safety: a framework for pediatric patient safety improvement
 PIPSQC - accelerating change - learning from each other to decrease healthcare-associated harm (slides)
 PIPSQC - IHI 25th Annual National Forum - PIPSQC workshop 2013
 PIPSQC - International Forum on Quality & Safety in Healthcare - PIPSQC workshop 2012 
 PIPSQC - PIPSQC roundtable discussion 2006
 Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the paediatric trigger tool
 Preventing health care-associated harm in children
 Principles of pediatric patient safety: reducing harm due to medical care
 Quality of care for pregnant women and newborns - the WHO vision
 Reducing mortality related to adverse events in children
 Safe pediatric care delivery
 Top 10 interventions in paediatric patient safety
 WHO - better hospital care for children
 WHO - improving paediatric quality of care at first-level referral hospitals
 WHO - launch of the network to improve quality of care for mothers, newborns and children
 WHO - maternal, newborn, child and adolescent health - documents on quality of care
 WHO - quality of care for every pregnant woman and newborn
 WHO - standards for improving quality of maternal and newborn care in health facilities

 Australia:
 CEC - patient safety programs

 Europe: 
 CQC - state of care in NHS acute hospitals: 2014 to 2016
 Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews
 Health Foundation - continuous improvement of patient safety
 Health Foundation - creating a new improvement research institute
 IHM - Review of Reviews
 Impact of medical errors and malpractice on health economics, quality, and patient safety
 Imperial College London - patient safety 2030
 Imperial College London - reports
 Imperial College London - safer healthcare: strategies for the real world
 Imperial College London - too many avoidable errors in patient care, says report
 Imperial College London - transforming patient safety: a sector-wide systems approach
 More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?
 Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
 NHS England - priority areas for patient safety collaboratives
 NHS Scotland - chief medical officer's annual report (2014-15) - realistic medicine
 NHS 'standing on burning platform' of outdated acute care model
 Patient safety is not a luxury
 Rethinking patient safety

 North America: 
 8 ways to improve hospital patient safety - efforts start with culture, say leaders at the NPSF Congress
 AHRQ - AHRQ supports hospitals as they make care safer
 AHRQ - chartbook on patient safety
 AHRQ - making health care safer II - an updated critical analysis of the evidence for patient safety practices
 AHRQ - national patient safety efforts save 125,000 lives and nearly $28 billion in costs
 AHRQ - national quality strategy - making care safer
 AHRQ - national scorecard on rates of hospital-acquired conditions 2010 to 2015: interim data from national efforts to make health care safer
 AHRQ - patient safety measure tools & resources
 AHRQ - patient safety measure tools & resources - patient safety tools & resources
 AHRQ - strengthening AHRQ's role in preventing medical errors
 AHRQ - we're keeping score: reducing hospital-acquired conditions
 AHRQ PSNet - primers
 Building a highway to quality health care
 Changing the narratives for patient safety
 CIHI - hospital harm project
 CMS awards $347 million to continue progress toward a safer health care system
 CMS invites quality innovation network-quality improvement organizations to submit special innovation projects to expand their reach in improving care delivery
 CMS - Partnership for Patients (PfP)
 CMS - Partnership for Patients (PfP) - Hospital Engagement Network (HEN) 2.0 - final report
 CMS - Partnership for Patients (PfP) - Hospital Innovation Improvement Networks (HIINs)
 CMS - Partnership for Patients and the Hospital Improvement Innovation Networks: continuing forward momentum on reducing patient harm
 Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine
 Don Berwick's 7 roadblocks to improving patient safety
 Dr. Don Berwick: 5 big missteps on the patient safety journey
 ECRI Institute - top 10 health technology hazards for 2017
 ECRI Institute - top 10 patient safety concerns for healthcare organizations 2016
 Estimating deaths due to medical error: the ongoing controversy and why it matters
 Fifteen years after to err is human: a success story to learn from
 Fostering transparency in outcomes, quality, safety, and costs
 Hospital Engagement Network Results Show 34,000 Harms Prevented
 Hospital Safety Grade - lives lost and lives saved
 IHPME - beyond the quick fix: strategies for improving patient safety
 Improving safety for hospitalized patients - much progress but many challenges remain
 Joint Commission - national patient safety goals
 Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System
 Medical error-the third leading cause of death in the US
 NPSF - five notable developments in patient safety in 2016
 NPSF - free from harm: accelerating patient safety improvement fifteen years after to err is human
 NPSF - Institute for Healthcare Improvement and NPSF agree to merger
 NPSF - into the future with IHI, together for safer care
 NPSF - preventable health care harm is a public health crisis
 NPSF - time to step on the accelerator
 NPSF - transforming health care: a compendium of reports from the NPSF Lucian Leape Institute
 Patient safety at the crossroads
 Patient safety initiatives are everybody's business
 Patient Safety Movement - challenges & solutions
 Patient safety: a public health crisis for a nation of patients
 Pennsylvania Patient Safety Authority - health literacy and patient safety events - patient safety authority annual reports
 PIPSQC Blog - patient harm is a public health crisis, not just a performance management issue
 Preventable harm in healthcare a public health crisis
 Redefining patient safety in 2017 - 6 thoughts from IHI CEO Derek Feeley
 Rethinking medical ward quality
 Strategies to improve patient safety: the evidence base matures
 Top patient safety strategies that can be encouraged for adoption now
 What practices will most improve safety? Evidence-based medicine meets patient safety
 Why are medical errors still a leading cause of death?

 Global: 
 IHI - IHI's work around the world
 Federal Ministry of Health - best practices in patient safety: 2nd global ministerial summit on patient safety
 Federal ministry of health - economics of patient safety: strengthening a value-based approach to reducing patient harm at national level
 Federal Ministry of Health - patient safety summit 2017 - patient safety takes the front seat
 Joint Commission - international patient safety goals
 Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review
 SafeCare - SafeCare Standards - for health centres in resource-restricted settings
 WHO - African Partnerships for Patient Safety (APPS)
 WHO - global priority areas for patient safety research
 WHO - patient safety - implementing change
 WHO - patient safety tool kit (2015)
 WHO - quality of care for pregnant women and newborns: the WHO vision
 Peer-to-Peer (P2P) Assessment  Clinical perspective: creating an effective practice peer review process - a primer
 Five lessons healthcare leaders are learning from an unlikely source: nuclear power
 Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers
 Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry
 Toward improving patient safety through voluntary peer-to-peer assessment
 Poisoning Prevention  CDC - PROTECT initiative: advancing children's medication safety
 Institute for Safe Medication Practices and poison control centers: collaborating to prevent medication errors and unintentional poisonings
 NHS - patient safety alert - risk of death and serious harm from delays in recognising and treating ingestion of button batteries 
 Re-ACT Talks: Batteries, Burns and other Bombs
 Precision Public Health  CDC - precision public health and precision medicine: two peas in a pod 
 Dr. Susan Desmond-Hellmann, Guide of the Gates Foundation 
 Medscape - 'all lives have equal value': reducing inequality with precision public health
 Precision public health: big data's next big idea 
 TED - a smarter, more precise way to think about public health 
 UCSF - precision public health summit: the first 1000 days 
 Why The First 1,000 Days Matter Most
 Prehospital Care           See 'Emergency Medical Services (EMS)'
 Primary Care  See 'Ambulatory Care'
 Quality Measures  See 'Patient Safety Indicators (PSIs)'
 Radiation in Imaging  ACR - pediatric radiation safety 
 Alliance for Radiation Safety in Pediatric Imaging - Image Gently 
 Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering
 Key principles in quality and safety in radiology
 Pediatric chest radiographs: common and less common errors
 Overuse of medical imaging and its radiation exposure: who's minding our children?
 Quality improvement in pediatric head trauma with PECARN rules implementation as computerized decision support
 Radiologic safety events within a pediatric emergency medicine network
 Radiology research in quality and safety: current trends and future needs
 Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies
 WHO - communicating radiation risks in paediatric imaging - information to support healthcare discussions about benefit and risk
 WHO - international workshop on radiation risk communication in paediatric imaging
 Rapid Response Team (RRT)  ACSQHC - recognising and responding to clinical deterioration - guide to implementation of the national consensus statement 
 CHEO - CHEO's SPOT Team - family activated critical care response team 
 Cincinnati Children's - emergency codes outside the ICU 
 Cost-benefit analysis of a medical emergency team in a children’s hospital 
 Developing and evaluating the success of a family activated medical emergency team: a quality improvement report 
 High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training
 Impact of implementation of family-initiated escalation of care for the deteriorating patient in hospital: a systematic review 
 Improving the recognition of, and response to in-hospital sepsis
 Josie King Foundation - Condition Help (Condition H) 
 Multicenter collaborative approach to reducing pediatric codes outside the ICU
 NUH - Recognise and Rescue: A hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals NHS Trust 
 NUH - 'Recognise and Rescue' - improving the care of the deteriorating pediatric patient 
 Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams
 Pediatric medical emergency team events and outcomes: a report of 3647 events from the American Heart Association's Get With the Guidelines-Resuscitation registry 
 Queensland Health - Ryan's Rule - consumer/family escalation process
 Rapid response systems: a systematic review and meta-analysis 
 Real-time risk prediction on the wards: a feasibility study 
 Royal Children's - escalation of care flowchart
 Royal Children's - Victorian Children's Tool for Observation and Response (ViCTOR)
 Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides)
 Readmissions and Care Transitions  Paediatric:  
 CAPHC - 'Passport' helps parents plan move from hospital to home
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS bundles - readmissions 
 Pediatric hospitalists collaborate to improve timeliness of discharge communication

 General: 
 30-day potentially avoidable readmissions due to adverse drug events
 AHRQ - designing and delivering whole-person transitional care: hospital guide to reducing Medicaid readmissions
 AHRQ - Re-Engineered Discharge (RED) toolkit 
 An Obamacare success: financial penalties reduce hospital readmission rates
 Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions
 Bigger readmissions penalties linked to declining rates
 Carelink CareNow
 CMS - Partnership for Patients (PfP) - readmissions and care transitions 
 Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic
 HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program
 Identifying and reducing complications after emergency room discharge
 Impact of discharge planning decision support on time to readmission among older adult medical patients 
 Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study
 Improving communication with primary care physicians at the time of hospital discharge
 Joint Commission - Transitions of Care (ToC) portal 
 Leveraging the Partnership for Patients' initiative to improve patient safety and quality within the Military Health System
 Nationwide Readmissions Database (NRD)
 NPSF - creating structure for sharing information and knowledge in ambulatory care: two exemplars
 Readmission rates after passage of the Hospital Readmissions Reduction Program: a pre-post analysis
 Reducing Avoidable Hospital Readmissions (RARE) 
 Understanding patient-centred readmission factors: a multi-site, mixed-methods study
 Using automated surveillance to improve diagnosis
 Reporting  AHRQ - Patient Safety Organization (PSO) program 
 Barriers and facilitators of adverse event reporting by adolescent patients and their families
 BC Children's - establishing a pediatric family-initiated safety reporting program (slides)
 BC Children's - patient's view: seeing safety through the eyes of families at BC Children’s Hospital 
 BC Children's - what a family perspective teaches about adverse events in the pediatric setting (slides) 
 Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention
 CHA - Child Health Patient Safety Organization (PSO) 
 CMS validated hospital inpatient quality reporting program data, but should use additional tools to identify gaming
 Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU
 Effects of power, leadership and psychological safety on resident event reporting
 Electronic approaches to making sense of the text in the adverse event reporting system
 EngagingPatients.org - patient and family reporting: new knowledge, new advances
 Families as partners in hospital error and adverse event surveillance
 Impact of hazard telephone reporting system on patient safety
 Imperial College London - too many avoidable errors in patient care, says report
 Implementation and evaluation of a prototype consumer reporting system for patient safety events
 Improvement approach to integrate teaching teams in the reporting of safety events
 Improving patient safety reporting with the common formats: common data representation for Patient Safety Organizations
 Increasing patient safety event reporting in an emergency medicine residency
 Informing the design of a new pragmatic registry to stimulate near miss reporting in ambulatory care
 Innovative use of the electronic health record to support harm reduction efforts 
 International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process
 ISMP - using information from external errors to signal a "clear and present danger"
 Learning from Excellence (LfE) - a call to learn from what goes well in healthcare 
 Learning from excellence in healthcare: a new approach to incident reporting 
 Legislative report to the general assembly: adverse event reporting
 Making residents part of the safety culture: improving error reporting and reducing harms
 Measurement as a performance driver: the case for a national measurement system to improve patient safety
 Medicare failed to investigate suspicious infection cases from 96 hospitals
 Multilevel analysis of U.S. hospital patient safety culture relationships with perceptions of voluntary event reporting
 NHS - organisation patient safety incident reports
 NHS - Children and Young People's Services (C&YPS) Safety Thermometer
 NHS England - Development of the Patient Safety Incident Management System (DPSIMS)
 NPSF - patient complaints and post-operative complications
 Operational failures detected by frontline acute care nurses
 Parent-reported errors and adverse events in hospitalized children
 Patient reported approach to identify medical errors and improve patient safety in the emergency department
 Patient reporting and action for a safe environment (PRASE) intervention: a feasibility study
 Patient safety incidents are common in primary care: a national prospective active incident reporting survey
 PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety
 Safety App 
 Screening electronic health record-related patient safety reports using machine learning
 Secret data on hospital inspections may soon become public
 Using an inpatient portal to engage families in pediatric hospital care
 Why are medical errors still a leading cause of death?
 Researcher-in-Residence  Moving improvement research closer to practice: the Researcher-in-Residence model
 Resident Physicians  See 'Junior Doctors'
 Resuscitation  See 'CPR and Resuscitation'
 Reverse Innovation  IHI - a two-way street: what the united states can learn from resource-limited countries to improve health care delivery and reduce costs
 Reverse innovation in global health systems: learning from low-income countries 
 Turning the World Upside Down: The Search for Global Health in the 21st Century
 WHO - turning the world upside down 
 Root Cause Analysis (RCA)  AHRQ PSNet - conversation on root cause analysis w Dr. Bagian
 AHRQ PSNet - rethinking root cause analysis
 Design and testing of BACRA, a web-based tool for middle managers at health care facilities to lead the search for solutions to patient safety incidents
 How to perform a root cause analysis for workup and future prevention of medical errors: a review
 Improving apparent cause analysis reliability: A quality improvement initiative
 Investigating the causes of adverse events
 NPSF - implementing root cause analysis and actions: lessons learned from the journey
 NPSF - RCA2: improving root cause analyses and actions to prevent harm
 Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
 Patient Safety: investigating and reporting serious clinical incidents
 Retained lumbar catheter tip
 Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education
 Root-cause analysis: swatting at mosquitoes versus draining the swamp
 Unbundling the bundles: using apparent and systemic cause analysis to prevent health care-associated infection in pediatric intensive care units
 Safety Culture  AHA - HPOE - profiles in excellence: quality improvement lessons from the AHA-Mckesson Quest for Quality Prize recipients part 1
 AHRQ - hospital survey on patient safety culture 
 AHRQ PSNet - primers - safety culture
 As a critical behavior to improve quality and patient safety in health care: speaking up!
 ASSI - safety culture 
 Building a culture of safety in pediatrics and child health
 Building a high-reliability organization: one system's patient safety journey
 Center for Patient Safety - just culture
 Changing the narratives for patient safety 
 Children's Hospitals' Solutions for Patient Safety (SPS) - network design & process 
 Cincinnati Children's - 'Being the best at getting better' - creating a culture of change
 CMS - Partnership for Patients (PfP) - culture 
 Common predictors of nurse-reported quality of care and patient safety 
 Comparing NICU teamwork and safety climate across two commonly used survey instruments
 Core principles of quality improvement and patient safety
 CQC - state of care in NHS acute hospitals: 2014 to 2016
 Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine
 Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation
 Do hospital boards matter for better, safer, patient care?
 Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction
 Exploring relationships between hospital patient safety culture and Consumer Reports safety scores
 From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system
 Health Foundation - continuous improvement of patient safety
 Health Foundation - framework for measuring and monitoring safety
 Health Foundation - measurement and monitoring of safety
 Health Foundation - pursuing zero - a winning approach to safety
 Health Foundation - what we know about how to improve quality and safety in hospitals - and what we need to learn
 Healthcare Performance Improvement (HPI) 
 HRET - Hospital Engagement Network (HEN) 2.0 - culture of safety              
 IHI - building systems of safety 
 IHI - decision tree for unsafe acts culpability
 IHI - develop a culture of safety
 IHI - framework for safe, reliable, and effective care
 IHI - IHI virtual expedition: understanding and improving safety culture
 IHI - patient safety framework
 IHI: this way to patient safety
 Imperial College London - safer healthcare - strategies for the real world
 Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system
 Joint Commission - essential role of leadership in developing a safety culture
 Joint Commission - getting the board on board: what your board needs to know about quality and safety, third edition
 Joint Commission - quick safety 22: patient safety systems chapter
 Joint Commission - safety culture and high reliability: stages of organizational maturity
 Joint Commission Center for Transforming Healthcare - safety culture 
 Just culture: balancing safety and accountability, third edition
 'Just culture:' improving safety by achieving substantive, procedural and restorative justice
 KK Women's and Children's Hospital - patient safety - building a reliable culture for a sustainable outcome
 Long and winding road toward greater quality and safety - Memorial Hermann and Virginia Mason health systems make big leaps in improving patient safety
 Massachusetts Coalition for the Prevention of Medical Errors - 2017 Patient Safety Forum
 MedStar Health - quality and patient safety - quality & safety videos
 MedStar Health - safety across the board: integrating "just culture", high reliability, and open, honest communication
 Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment
 Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach
 NHS - developing people - improving care - a national framework for action on improvement and leadership development in NHS-funded services
 NPSF - leading a culture of safety: a blueprint for success
 Outcome Engenuity - introduction to just culture
 Patient safety at the crossroads
 Patient safety efforts need engaged leaders
 Pediatric quality and safety: a nursing perspective
 Preventable Harm Index: an effective motivator to facilitate the drive to zero 
 Prevention is better than cure: learning from adverse events in healthcare
 Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study
 RCPCH - safe system framework for children at risk of deterioration
 Re-examining high reliability: actively organising for safety 
 Rethinking patient safety 
 Revisiting the quality chasm
 Quality and Safety in European Union Hospitals - a research-based guide for implementing best practice and a framework for assessing performance (QUASER) 
 Quality and safety in nursing: a competency approach to improving outcomes, second edition
 Safety culture transformation: its effects at a children's hospital
 Safety lessons from the NIH clinical center
 Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety 
 Safety perceptions of health care leaders in 2 Canadian academic acute care centers
 SickKids - Caring Safely
 Sidney Dekker - safety differently - talks
 Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents
 Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies
 Systematic review of measurement tools for the proactive assessment of patient safety in general practice
 Towards high-reliability organising in healthcare: a strategy for building organisational capacity
 WSHA - toolkit: patient safety transforming culture
 Safety-II and Resilience Engineering  Centre for Applied Resilience in Healthcare (CARe) - fact sheets 
 Centre for Applied Resilience in Healthcare (CARe) - implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol
 David Woods - creating safety by engineering resilience
 Defining the role of social sciences in patient safety (special issue) 
 Erik Hollnagel - ideas 
 Eurocontrol - from safety I to safety II - a white paper
 Eurocontrol - systems thinking for safety: ten principles - a white paper - moving towards safety-II
 Humanistic Systems - systems thinking for safety: ten principles (a white paper)
 IHI - framework for safe, reliable, and effective care
 IHI: this way to patient safety
 International prize in resilient health care
 Learning from Excellence - Adrian Plunkett (video)
 Learning from Excellence (LfE) - a call to learn from what goes well in healthcare 
 Learning from excellence in healthcare: a new approach to incident reporting 
 National Center for Human Factors in Healthcare - resilience engineering in health care 
 Reliability engineering & system safety - resilience engineering (special issue)
 Resilience and precarious success: how human adaptation keeps patients safe
 Resilience and resilience engineering in health care
 Resilient Health Care Net (RHCN)
 Resilient Health Care Net (RHCN) - is counting accidents a measure of safety?
 Resilient Health Care Net (RHCN) - from safety-I to safety-II: a white paper
 Resilient Health Care Net (RHCN) - meeting presentations 2016
 Resilient Health Care Net (RHCN) - overview of the Resilience Assessment Grid (RAG)
 Resilient Health Care Net (RHCN) - resilient health care: turning patient safety on its head 
 Resilient Health Care Net (RHCN) - safety II: actuated
 Resilient health care, volume 3: reconciling work-as-imagined and work-as-done
 Safety-I, Safety-II and resilience engineering 
 Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems
 Second Victim  See 'Employee Safety'
 Sentinel Events  Correlates of the third victim phenomenon
 CPSI - Global Patient Safety Alerts 
 CPSI - never events for hospital care in Canada 
 ISMP - using information from external errors to signal a "clear and present danger"
 Leapfrog - one in five U.S. hospitals fail to adopt crucial 'Never Events' policies
 Joint Commission - sentinel event alert
 'Never Events' and the quest to reduce preventable harm
 NQF - serious reportable events
 Prevention is better than cure: learning from adverse events in healthcare
 Retained lumbar catheter tip
 Secret data on hospital inspections may soon become public
 Sepsis  Fluid Restriction: 
 
Challenges for treating sepsis in African children (slides) 
 Combined feasibility and external pilot study to inform the design and conduct of the Fluids in Shock (FiSh) trial 
 Conservative vs. liberal approach to fluid therapy of septic shock in intensive care (CLASSIC)
 FEAST - 5 years on
 FEAST and paediatric fluid resuscitation 
 Fluids and kids: what now? (slides) 
 Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice 
 Mortality after fluid bolus in African children with severe infection 
 Pediatric sepsis and septic shock management in resource-limited settings
 Predicting mortality in sick African children: the FEAST Paediatric Emergency Triage (PET) Score 
 SQUEEZE trial: trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal directed fluid-sparing strategy vs. usual care (SQUEEZE)
 WHO guidance 'risks killing children' 
 WHO guidelines on fluid resuscitation in children: missing the FEAST data
 WHO - paediatric emergency triage, assessment and treatment (ETAT): care of critically-ill children - updated guideline

 Australia:
 
CEC - Sepsis Kills - toolkit - paediatric  
 Improving the recognition of, and response to in-hospital sepsis
 SEPSIS KILLS: early intervention saves lives

 Europe: 
 Comparison of pediatric severe sepsis managed in U.S. and European ICUs 
 HSE - sepsis - sepsis management national clinical guideline No. 6 
 Leicester Hospital - Paediatric Sepsis Box
 Making the journey safe: recognising and responding to severe sepsis in accident and emergency
 NHS 111 'missed chances to save sepsis baby William Mead'
 NHS Wales - 1000 Lives Improvement - Sepsis Six Pathway box
 NICE - sepsis: recognition, diagnosis and early management
 NUH - Recognise and Rescue: a hospital-wide collaboration to improve response to the deteriorating patient at Nottingham University Hospitals
 NUH - 'Recognise and Rescue' - improving the care of the deteriorating pediatric patient 
 Rocialle's new Single-Use Sepsis Box is being trialled by Cwm Taf UHB
 Sepsis in children - what is in a name?  
 Single-use kit aims to reduce the risk of sepsis
 SPSP - paediatric care - Paediatric Sepsis 6
 UK Sepsis Trust - acute paediatric toolkit
 UK Sepsis Trust - acute paediatric toolkit - Paediatric Sepsis 6
 Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care

 North America: 
 Ambient Clinical Analytics - syndromic surveillance - Sepsis Detection and Response Tool (Sepsis DART) 
 Automated detection of sepsis using electronic medical record data: a systematic review
 Boy's life is lost to sepsis. Thousands are saved in his wake
 CAPHC - Canada's ambitions for pediatric sepsis screening: from today's best practice to precision medicine
 CAPHC - global burden of sepsis: World Sepsis Day, September 13 
 CAPHC - paediatric sepsis: importance of data as a foundation for improvement
 CAPHC - Paediatric Sepsis Screening Tool 
 CAPHC - please join us in thanking the CAPHC sepsis community of practice
 CDC - Think Sepsis. Time Matters. 
 CHA - children's hospitals have a voice at national sepsis forum
 CHA - Improving Pediatric Sepsis Outcomes (IPSO) 
 CHA - join the fight against pediatric sepsis with new collaborative 
 CHA - national sepsis expert: children's hospitals can mobilize to reduce severe sepsis and sepsis deaths
 CHA - nursing on the front lines of the battle against pediatric sepsis: a webinar for clinicians
 CHA - sepsis 
 CHA - sepsis awareness month 
 CHA - sepsis: battling a leading cause of death in hospitalized children 
 CHA - sepsis webinar series
 Cincinnati Children's - new test accurately predicts mortality risk in pediatric septic shock 
 Cincinnati Children's - sepsis alert trigger and automated team response
 Clinical decision support for early recognition of sepsis 
 Developing the surveillance algorithm for detection of failure to recognize and treat severe sepsis 
 HRET - Hospital Engagement Network (HEN) 2.0 - sepsis 
 Identifying patients with sepsis on the hospital wards
 IHI - WIHI: a partnership to reduce deaths from sepsis
 Infection, unnoticed, turns unstoppable
 Implementation of an inpatient pediatric sepsis identification pathway 
 New York State report on sepsis care improvement initiative: hospital quality performance (2015)
 Reductions in sepsis mortality and costs after design and implementation of a nurse-based early recognition and response program 
 Rory Staunton Foundation - sepsis protocols 
 Rory Staunton Foundation - Rory's Regulations 
 Sepsis in Canadian children: a national analysis using administrative data 
 SickKids piloting new pathway for early recognition & management of sepsis 
 State sepsis mandates - a new era for regulation of hospital quality
 Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study 
 Texas Children's - confronting complexity and improving sepsis care: resilience and human factors - Code Sepsis program (slides)
 Vital signs: epidemiology of sepsis: prevalence of health care factors and opportunities for prevention
 With help from IHI, North Shore-LIJ reduces sepsis mortality rate by 50% in 5 years, saving thousands of lives

 Global: 
 
Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations.
 CAPHC - misdiagnosed 'sepsis' now a global health priority for world health organization
 Functional outcomes in pediatric severe sepsis: further analysis of the researching severe sepsis and organ dysfunction in children: a global perspective trial 
 International Pediatric Association (IPA) - joint statements - managing possible serious bacterial infection in young infants 0-59 days old when referral is not feasible
 Key points in pediatric sepsis and septic shock (slides) 
 Multimodal monitoring for hemodynamic categorization and management of pediatric septic shock: a pilot observational study
 OPENPediatrics - the burden of sepsis in children (webinar) 
 OPENPediatrics - sepsis in the critically ill child (webinar) 
 Pediatric sepsis and septic shock management in resource-limited settings
 PICC 2016 - sepsis: moving forward 
 PICC 2016 - session summaries - sepsis sessions 1 & 2 
 Sepsis Global Alliance (SGA)
 Sepsis guideline implementation: benefits, pitfalls and possible solutions 
 Sepsis - a neglected global killer (slides)
 Stop sepsis - the Global Sepsis Alliance (slides) 
 Surviving Sepsis Campaign - guidelines 
 Third international consensus definitions for sepsis and septic shock (Sepsis-3)
 WFPICCS - sepsis initiative 
 WHO - critical care training short course - clinical management of patients with severe forms of influenza infection
 WHO - Ending Maternal and Newborn Sepsis Week 2017
 WHO - Global Maternal and Newborn Sepsis Initiative
 WHO - innovation through partnership - achieving more together than alone 
 WHO - management of newborn illness and complications
 WHO - managing possible serious bacterial infection in young infants when referral is not feasible
 World Sepsis Congress 
 World Sepsis Congress - burden of sepsis in children - innovative critical care
 World Sepsis Congress - challenges of sepsis management in low-income settings 
 World Sepsis Congress - effective interventions for mothers and newborns
 World Sepsis Congress - program 
 Serious Safety Events (SSEs)  ASHRM - serious safety events: a focus on harm classification - deviation in care as link 
 ASHRM - serious safety events: getting to zero™ white paper edition no. 1

 ASHRM - serious safety events: getting to zero™ white paper edition no. 2 
 Children's Hospitals' Solutions for Patient Safety (SPS) - SPS operational definitions - SSEs 
 Cincinnati Children's - serious safety events
 Correlates of the third victim phenomenon
 Healthcare Performance Improvement (HPI) - SEC & SSER patient safety measurement system for healthcare 
 NHS England - serious incident framework
 Patient Safety: investigating and reporting serious clinical incidents
 Preventable Harm Index: an effective motivator to facilitate the drive to zero
 Simulation  Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training
 Building a culture of patient safety through simulation 
 CHA - simulation lab helps parents prepare to care for kids at home
 Cincinnati Children's - 'learning from dummies'
 Developing team cognition: a role for simulation
 Emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives 
 Flying lessons for clinicians: developing system 2 practice
 Healthcare simulation dictionary
 High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training
 Hybrid methodology for modeling risk of adverse events in complex health-care settings
 Imperfect practice makes perfect: error management training improves transfer of learning
 In situ simulation 
 In situ simulation: detection of safety threats and teamwork training in a high risk emergency department
 International Network for Simulation-based Pediatric Innovation, Research, & Education (INSPIRE)
 International Pediatric Simulation Society (IPSS)
 PRONTO - simulation & team training for obstetric & neonatal emergencies 
 Realism in simulation: how much is enough?
 Resilient Health Care Net (RHCN) - resilience and simulation redux
 'See one, sim one, do one' - a national pre-internship boot-camp to ensure a safer 'student to doctor' transition 
 Simulation, mastery learning and healthcare
 Simulation for operational readiness in a new freestanding emergency department: strategy and tactics
 Simulation to predict effect of citywide events on emergency department operations
 Simulation-based training: the missing link to lastingly improved patient safety and health? 
 Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls
 Using simulation to prepare nursing staff for the move to a new building
 Situation Awareness  Ambient Clinical Analytics - Mayo Clinic YES Board - multi-patient dashboard | real-time situational awareness
 Cincinnati Children's - CERT - CCHMC safety and risk-reduction projects
 Developing team cognition: a role for simulation
 Evaluating situation awareness: an integrative review
 Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis
 Health care huddles: managing complexity to achieve high reliability 
 Healthcare Performance Improvement (HPI) - daily check in for safety
 Huddles and debriefings: improving communication on labor and delivery
 Huddling for high reliability and situation awareness
 IHI - WIHI: situational awareness and patient safety (webinar) 
 Implementation of the safety huddle
 Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events 
 Model can ID patients at risk for serious safety events
 PIPSQC - S.A.F.E - improving child health outcomes through situation awareness
 RCPCH - Situation Awareness for Everyone (S.A.F.E) 
 Safety huddles to proactively identify and address electronic health record safety
 Situation awareness: a new model for predicting and preventing patient deterioration 
 Situational awareness and emergent response systems in the context of stages of clinical deterioration in the hospital 
 Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system
 Situational awareness - what it means for clinicians, its recognition and importance in patient safety
 SPSP - paediatric care - increased situational awareness to reduce undetected deterioration
 Step toward high reliability: implementation of a daily safety brief in a children's hospital 
 Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards
 UHN - daily unit safety huddles part of Caring Safely transformation at UHN
 Sleep and SIDS  AAP - SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment
 Interventions to improve safe sleep among hospitalized infants at eight children's hospitals
 Swaddling and the risk of sudden infant death syndrome: a meta-analysis
 To avoid SIDS, infants and parents should share a room, report says
 Tuck - parent's guide to healthy sleep
 Staffing  Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England
 Association between elements of electronic health record systems and the weekend effect in urgent general surgery
 'Busy day' effect on perinatal complications of delivery on weekends
 Doctors who only come out at night
 Introducing a new junior doctor electronic weekend handover on an orthopaedic ward
 Is the "July Effect" real? Pediatric trainee reported medical errors and adverse events
 Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records
 NHS England - seven day hospital services 
 NHS England - supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time 
 Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care
 Nurses drive change in patient safety improvements
 Time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect?
 Weekend effect in children with stroke in the nationwide inpatient sample 
 "Weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend
 Weekend emergency surgery 'not more risky'
 Weekend worriers
 What have we learnt after 15 years of research into the 'weekend effect'?
 Standardisation of Care  See 'Cinical Effectiveness and Standardisation'
 Surgery  Checklists: 
 Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial
 Enhanced time out: an improved communication process 
 Factors that drive team participation in surgical safety checks: a prospective study 
 Impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility
 Impact of surgical safety checklists on theatre departments: a critical review of the literature 
 Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care
 Innovative approach to the surgical time out: a patient-focused model
 Instrument count sheets and set reviews as patient safety tools
 Introductions during time-outs: do surgical team members know one another's names?
 Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study
 Mobilising or standing still? A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016
 Mortality trends after a voluntary checklist-based surgical safety collaborative
 Moulton Lab - slowing down to stay out of trouble in the operating room: remaining attentive in automaticity
 Operating room clinicians' attitudes and perceptions of a pediatric surgical safety checklist at 1 institution 
 Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies
 Safe Surgery 2015 - safe surgery checklist implementation guide
 Safesurg.org - how to reduce deaths in surgical care globally - materials 
 Safesurg.org - other institutions' checklists 
 Simple checklist prevents deaths after surgery, a large new study suggests
 Time-out and checklists: a survey of rural and urban operating room personnel
 Time-out: the professional and organizational ethics of speaking up in the OR
 Tools and the trade: an ethnographic study of checklist policy and performance, and implications for patient safety
 WHO - Surgical Safety Checklist

 Paediatric:  
 A lost voice: Surgery was supposed to mean a better life for Talia. But something went wrong
 ACS National Surgical Quality Improvement Program Pediatric (ACS NSQIP Pediatric) 
 ACS National Surgical Quality Improvement Program: targeting quality improvement in Canadian pediatric surgery 
 Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room
 BC Children's - team behaviours and non-technical skills in a paediatric surgical facility (slides)
 Improving pediatric surgery quality and outcomes in the 21st century (special issue) 
 National aeronautics and space administration 'threat and error' model applied to pediatric cardiac surgery: error cycles precede ~85% of patient deaths 
 Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery
 Nontechnical skills in pediatric surgery: factors influencing operative performance
 Optimal resources for children's surgical care 2015
 Patient safety improvement interventions in children's surgery: a systematic review
 'Weekend effect' in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend 
 
 General: 
 ACS National Surgical Quality Improvement Program (ACS NSQIP)
 ACS NSQIP Annual Conference - 2016 presentations
 ACS Updates Guidelines Regarding Overlapping Surgeries
 AHRQ - safety program for improving surgical care and recovery
 AHRQ - toolkit to improve safety in ambulatory surgery centers
 AORN position statement on patient safety
 Applying human-centered design thinking to enhance safety in the OR
 Association between implementation of a medical team training program and surgical mortality
 Association of periOperative Registered Nurses (AORN) - clinical resources
 Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training
 Association of unsolicited patient observations with the quality of a surgeon's care
 Brigham and Women's - Center for Surgery and Public Health
 Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program
 Computer-assisted process modeling to enhance intraoperative safety in cardiac surgery
 Concurrent and overlapping surgeries: additional measures warranted
 Current issues in patient safety in surgery: a review
 Cutting-edge efforts in surgical patient safety
 Failures in communication and information transfer across the surgical care pathway: interview study
 Fundamental Use of Surgical Energy (FUSE): an essential educational program for operating room safety
 Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries
 Implementing a standardized safe surgery program reduces serious reportable events 
 Improving Rescue - bringing about collaboration to improve safety and quality of care
 Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data
 Joint Commission Center for Transforming Health - safe surgery project
 Learning and mindfulness: improving perioperative patient safety
 Medication safety in the operating room: literature and expert-based recommendations
 Microanalysis of video from the operating room: an underused approach to patient safety research
 Next wave of hospital innovation to make patients safer
 NPSF - patient complaints and post-operative complications
 On patient safety (special issue)
 Promoting civility in the OR: an ethical imperative
 Realism in simulation: how much is enough? 
 Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis
 Senate committee calls for ban on surgeons conducting simultaneous operations
 Structured handover in general surgery: an audit of current practice 
 Surgeon, heal thyself: optimising surgical performance by managing stress
 Surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) study
 Surgical clinics - patient safety (special issue)
 Surgical never events and contributing human factors 
 Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture
 Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications
 We are going to name names and call you out! Improving the team in the academic operating room environment
 WHO - Safe Surgery Saves Lives
 Teamwork Training  AHRQ - high reliability organizational culture using standardized patient simulation and TeamSTEPPS

 AHRQ - TeamSTEPPS 2.0
 Amy Edmondson: Teaming
 Amy Edmondson's required reading 
 Building the future: big teaming for audacious innovation
 Building high reliability teams: progress and some reflections on teamwork training Challenging hierarchy in healthcare teams - ways to flatten gradients to improve teamwork and patient care 
 Developing team cognition: a role for simulation
 Examining the nature of interprofessional interventions designed to promote patient safety: a narrative review
 Google considers this to be the most critical trait of successful teams
 Harvard Business School - Amy C. Edmondson - faculty page 
 Importance of teaming
 Improving care teams' functioning: recommendations from team science
 Interview with Amy C. Edmondson, author of "Teaming" by William Brandel, RCRC, Brandeis University
 Monitoring teamwork: a narrative review
 Patient safety improves when providers feel psychologically safe (video)
 Power of teaming (slides)
 Principles of shared decision-making within teams
 Saving lives: a meta-analysis of team training in healthcare
 Strategies for learning from failure (video)
 Systematic review of team training in health care: ten questions
 Team building and beyond - interview with Amy Edmondson, Harvard Business School (video)
 Team up, fail well, learn fast (slides)
 Teaming: how organizations learn, innovate, and compete in the knowledge economy
 Teaming to innovate
 Teaming to innovate (slides)
 Teams and learning in organizations (video)
 Teamwork on the fly
 Teamwork on the fly (excerpt) (PDF)
 TEDx - building a psychologically safe workplace: Amy Edmondson at TEDxHGSE (video)
 The Art Of - Amy Edmondson
 Thought leader interview: Amy Edmondson (PDF)
 Three pillars of a teaming culture

 Telemedicine      See 'eHealth, mHealth, and Telehealth'
 Transport  CAPHC - update - standards in interfacility transport of critically ill neonatal, paediatric and maternal patients
 Children's Acute Transport Service (CATS) - standard operating procedures 
 Pediatric and neonatal interfacility transport: results from a national consensus conference
 Systematic review of the prevalence and types of adverse events in interfacility critical care transfers by paramedics
 Trigger Tools  See 'Adverse Event Detection'
 Triple Aim  IHI - 10 new rules to accelerate healthcare redesign 
 IHI - radically redesigning patient safety
 IHI - Triple Aim initiative - better care for individuals, better health for populations, and lower per capita costs 
 Quadruple Aim: care of the provider 
 Triple Aim must turn into the Quadruple Aim. Here’s why. 
 Why healthcare organizations must embrace the 'Quadruple Aim' 
 Tubing Misconnections  See 'Medical Devices'
 Universal Health Coverage  WHO - global coalition calls for acceleration of access to universal health coverage
 WHO - service delivery and safety - quality in universal health coverage
 Unplanned Extubations  Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates 
 Children's National - reducing harm: impact of unplanned extubations (pages 10-14) 
 Reducing unplanned extubations in the NICU 
 Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events
 Unplanned extubations in children: impact on hospital cost and length of stay 
 Walkrounds  HRET - patient safety leadership walkrounds
 HSE - quality and safety walk-rounds
 Intentional rounding: a staff-led quality improvement intervention in the prevention of patient falls
 Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws
 Weekend Effect  See 'Staffing'
 Work Environment  AACN - healthy work environment assessment 
 Monitoring the health of the work environment with a daily assessment tool: the REAL - Relative Environment Assessment Lens - indicator
 Work systems analysis approach to understanding fatigue in hospital nurses
 Workplace factors associated with burnout of family physicians
 Zika  AAP - Zika virus
 CAPHC - Zika virus: a global issue in a Canadian context
 CDC - Zika virus 
 CDC - Zika virus - information for clinicians
 CDC, AAP release algorithms on testing infants for Zika virus
 Premier - Zika virus infection guidance, tools and resources
 WHO - Zika virus 
 WHO - Zika: we must be ready for the long haul
 Zika virus disease: a CDC update for pediatric health care providers