| Selected Publications
Effect of computerized physician order entry with clinical decision support on adverse drug events in the long-term care setting. Gurwitz JH, Field TS, Rochon P, Judge J, Harrold LR, Bell CM, Lee M, White K, LaPrino J, Erramuspe-Mainard J, DeFlorio M, Gavendo L, Baril JL, Reed G, Bates DW. J Am Geriatr Soc 2008;56:2225-2233.
Several Center investigators and Executive Council members are contributing authors in Advances in Patient Safety: New Directions and Alternative Approaches
published in 2008 representing years of study by AHRQ-funded patient safety researchers and others. This new publication complements AHRQ's Advances in Patient Safety: From Research to Implementation, published in 2005.
Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Weissman JS, Schneider EC, Weingart SN, et al. Ann Intern Med 2008;149:100-108.
Minimizing diagnostic error: the importance of follow up and feedback . Schiff GD. Amer J of Med. 2008;121(5A):S38-S42.
A randomized trial of electronic clinical reminders to improve medication laboratory monitoring. Matheny ME, Sequist TD, Seger AC, Fiskio JM, Sperling M, Bugbee D, Bates DW, Gandhi TK. J Am Med Inform Assoc. 2008;15(4):424-9.
A model of recovering medical errors in the coronary care unit.
Hurley AC, Rothschild JM, Moore ML, Snydeman C, Dykes PC, Fotakis S. Heart Lung. 2008;37(3):219-26.
Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Am J Health Syst Pharm 2008;65(13):1254-1260.
A controlled trial of a rapid response system in an academic medical center. Rothschild JM, Woolf S, Finn KM, Friedberg MW, Lemay C, Furbush KA, Williams DH, Bates DW. Jt Comm J Qual Patient Saf 2008;34(7):417-425, 365.
Grand challenges in clinical decision support. Sittig DF, Wright A, Osheroff JA, Middleton B, Teich JM, Asj JS, Campbell E, Bates DW. J Biomed Inform 2008;41(2):387-392.
Medication safety messages for patients via the web portal: the MedCheck intervention. Weingart SN, Hamrick HE, Tutkus S, Carbo A, Sands DZ, Tess A, Davis RB, Bates DW, Phillips RS. Int J Med Inform 2008;77(3):161-168.
An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response. Staroselsky M, Volk LA, Tsurikova R, Newmark LP, Lippincott M, Litvak I, Kittler A, Wang T, Wald J, Bates DW. Int J Med Inform 2008;77(3):153-160.
Do medical inpatients who report poor service quality experience more adverse events and medical errors? Taylor BB, Marcantonio ER, Pagovich O, Carbo A, Bergmann M, Davis RB, Bates DW, Phillips RS, Weingart SN. Med Care 2008; 46 ( 2 ): 224-228 .
Medication safety. Keohane CA, Bates DW. Obstet Gynecol Clin N Am. 35(1):37-52, 2008 Mar.
Scope of problem and history of patient safety. Leape LL. Obstet Gynecol Clin N Am. 35(1):1-10, vii, 2008 Mar.
Quantifying nursing workflow in medication administration. Keohane CA, Bane AD, Featherstone E, Hayes J, Woolf S, Hurley A, Bates DW, Gandhi TK, Poon EG. J Nurs Adm. 2008;38(1):19-26.
Risk factors in preventable adverse drug events among pediatric outpatients. Zandieh SO, Goldmann DA, Keohane CA, Yoon C, Bates DW, Kaushal R. J Pediatr. 2008;152(02):225-231.
Costs of adverse events in intensive care units. Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Crit Care Med. 2007;35(22):2479-2483.
Case study on the use of health care technology to improve medication safety. Fiumara K, Moniz T, Churchill WM, Bane A, Luppi CJ, Bates DW, Gandhi TK. In: Medication use: a system approach to reducing errors, second edition. Porche RA, editor. Oakbrok, Illinois: Joint Commission Resources; 2007.pp.103-114.
Adverse drug events in pediatric outpatients. Kaushal R, Goldmann DA, Keohane CA, Cristino M, Honour M, Hale AS, Zigmont K, Lehmann LS, Perrin J, Bates DW. Ambul Pediatr. 2007 Sep-Oct:7(5):383-9.
Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders. Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH. J Amer Geriatrics Soc. 2007 Sep;55(9):145-7.
Medication safety in a psychiatric hospital. Gen Hospital Psychiatry. Rothschild JM, Mann K, Keohane CA, Williams DH, Foskett C, Rosen SL, Flaherty L, Chu JA, Bates DW. 2007 Mar-Apr;29(2):156-62.
The safety of warfarin therapy in the nursing home setting. Gurwitz JH, Field TS, Radford MJ, Harrold LR, Becker R, Reed G, DeBellis K, Moldoff J, Verzier N. Amer J Med. 2007 Jun;146(11):175-86.
Missed opportunities in the primary care management of early acute ischemia heart disease. Sequist TD, Marshall R, Lampert S, Beuchler E, Lee TH. Arch Intern Med. 2006 Nov 13;166(20):2237-2243.
Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Leape LL, Rogers G, Hanna D, Griswold P, Federico F, Fenn CA, Bates DW, Kirle L, Clarridge BR. Qual Safe Health Care. 2006 Aug; 15(4):289-95.
Disclosure of medical errors: what factors influence how patients respond? Mazur KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. J Gen Intern Med. 2006 Jul:21(7):704-10.The "To Err is Human" report and the patient safety literature. Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. Qual Saf Health Care. 2006 Jun;15(3):174-8.
Pediatric medication safety and the media: what does the public see? Stebbing C, Kaushal R, Bates DW. Pediatrics. 2006 Jun;117(6):1907-14.
Adverse drug events occurring following hospital discharge. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. J Gen Intern Med. 2005 Apr;20(4):317-23.
Prescribers' responses to alerts during medication ordering in the long term care setting. Judge J, Field TS, Deflorio M, Laprino J, Auger J, Rochon P, Bates DW, Gurwitz JH. J Am Med Inform Assoc. 2006 Apr 18.
Patient-reported service quality on a medicine unit. Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, Phillips RS, Bates DW. Int J Qual Health Care. 2006 Apr;18(2):95-101.
Full disclosure and apology—an idea whose time has come. Leape LL. Physician Exec. 2006 Mar-Apr;32:11-14.
When things go wrong: responding to adverse events. A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors.
Role of pharmacist counseling in preventing adverse drug events after hospitalization. Schnipper JL, Kirwin JL, Cotugno, Wahlstrom SA, Brown BA, Tarvin E, Horng M, Roy CL, Mckean SC, Bates DW. Arch Intern Med. 2006 Mar 13;166(5):565-71.
Serious adverse drug effects -- Seeing the trees through the forest. Gurwitz JH. New Engl J Med. 2006 Mar 1;354(13):1413-15.
Recovery from medical errors: the critical care nursing safety net. Rothschild JM, Hurley AC, Landrigan CP, Cronin JW, Martell-Waldrop K, Foskett C, Burdick E, Czeisler CA, Bates DW. Jt Comm J Qual Patient Saf. 2006 Feb;32(2):63-72.
Assessing the level of healthcare information technology adoption in the United States: a snapshot. Poon EG, Jha AK, Christino M, et al. BMC Med Inform Decis Mak. 2006 Jan 5;6:1.
How many hospital pharmacy medication dispensing errors go undetected? Cina JL, Gandhi TK, Churchill W, et al. Jt Comm J Qual Patient Safety. 2006;32:73-80.
Problem doctors: is there a system-level solution? Leape LL, Fromson JA. Ann Intern Med. 2006 Jan 17;144(2):107-15.
Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care. Rochon PA, Field TS, Bates DW, Lee M, Gavendo L, Erramuspe-Mainard J, Judge J, Gurwitz JH. CMAJ. 2006 Jan 3;174(1):52-4.
Potential medication dosing errors in outpatient pediatrics. McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J, Stull J, Debellis K, Andrade S, Miller M, Kaushal R, Gurwitz J, Davis RL. J Pediatr. 2005 Dec;147(6):761-7.
Residents report on adverse events and their causes. Jagsi R., Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Arch Intern Med . 2005 Dec 12-26;165(22):2607-13.
The costs associated with adverse drug events among older adults in the ambulatory setting.
Field TS, Gilman BH, Subramanian S , Fuller JC, Bates DW, Gurwitz JH. Med Care. 2005 Dec;43(12):1171-1176.
Medication safety in the ambulatory chemotherapy setting. Gandhi TK, Bartel SB, Shulman LM, Verrier D, Burdick E, Cleary A, Rothschild JM, Leape LL, Bates DW. Cancer. 2005 Dec 1;104(11):2477-83.
Closing the loop: follow-up and feedback in a patient safety program. Gandhi TK, Graydon-Baker E, Huber CN, Whittemore AD, Gustafson M. Jt Comm J Qual Patient Saf. 2005 Nov;31(11):614-21.
Ethical issues in patient safety. Leape LL. Thorac Surg Clin. 2005 Nov;15(4):493-501.
Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.
Keohane CA, Hayes J, Saniuk C, Rothschild JM, Bates DW. J Infus Nurs. 2005 Sep-Oct 28;(5):321-8.
Improving acceptance of computerized prescribing alerts in ambulatory care. Shah NR , Seger AC, Seger DL, Fiskio JM, Kuperman GJ, Blumenfeld B, Recklet EG, Bates DW, Gandhi TK. J Am Med Inform Assoc.
2006 Jan-Feb;13(1):5-11.
What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents.
Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, Bates DW, Phillips RS. J Gen Intern Med. 2005 Sep;20(9):830-6. Full text.
Outpatient prescribing errors and the impact of computerized prescribing. Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E, Poon EG, Leape LL, Bates DW. J Gen Intern Med. 2005; Sep 20(9):837-41.
Patient Safety Leadership WalkRounds at Partners HealthCare: Learning from Implementation. Frankel A., Grillo SP, Baher EG, Huber CN, Abookire S, Grenham M, Console P, O'Quinn M, Thibault G, Gandhi TK. Jt Comm J Qual Patient Safe. 2005 Aug;31(8):423-37.
Organizational change in the face of highly public errors. I. The Dana-Farber Cancer Institute experience. Conway JB, Weingart SN. AHRQ WebM&M.
Computerized physician order entry and medication errors: finding a balance. Bates DW. J Biomed Inform. 2005 Aug;38(4):259-61.
The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW. Crit Care Med. 2005;Aug;33:1694-1700.
What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors. Grasso BC, Rothschild JM, Jordan CW, Jayaram G. J Psychiatr Pract. 2005 Jul;11(4):268-73.
A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Rothschild JM, Keohane CA, Cook EF, Orav EJ, Burdick E, Thompson S, Hayes J, Bates DW. Crit Care Med. 2005 Mar;33(3):533-40.
Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter? Rosen AB, Blendon RJ, DesRoches CM, Benson JM, Bates DW, Brodie M, Altman DE, Zapert K, Steffenson AE, Schneider EC. Acad Med. 2005 Feb;80(2):189-92.
Communicating critical test results: safe practice recommendations. Hanna D, Griswold P, Leape LL, Bates DW. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):68-80.
Doing better with critical test results. Bates DW, Leape LL. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):66-7, 61.
Schiff GD, Kim S, Abrams R, Cosby K, Lambert B, Elstein AS, Krosnjar N, Odwazny R, Wisniewski MF, McNutt RA. Diagnosing diagnostic errors: Lessons from a multi-institutional collaborative project. In: Agency for Healthcare Research and Quality (AHRQ) Advances in Patient Safety: from Research to Implementation. Rockville, MD. 2005;2:225-264.
Patient-reported medication symptoms in primary care. Weingart SN, Gandhi TK, Seger AC, Seger DL, Borus J, Burdick E, Leape LL, Bates DW. Arch Intern Med. 2005 Jan 24;165(2):234-40.
Extended work shifts and the risk of motor vehicle crashes among interns. Barger LK,, Cade BE , Ayas NT, Cronin JW, Rosner B, Speizer EF, Czeisler CA; Harvard Work Hours, Work and Safety Group. N Engl J Med. 2005 Jan 13;352(2):125-34.
An interview with Lucian Leape. Leape LL. Jt Comm J Qual Saf. 2004 Dec;30(12):653-8.
Strategies for detecting adverse drug events among older persons in the ambulatory setting. Field TS, Gurwitz JH, Harrold LR, Rothschild JM, Debellis K, Seger AC, Fish LS, Garber L, Kelleher M, Bates DW. J Am Med Inform Assoc. 2004 Nov-Dec;11(6):492-98.
Patient satisfaction profiling of individual physicians: impact of panel status. Murff HJ, Orav EJ, Lee TH, Bates DW, Fairchild DG. J Eval Clin Pract. 2004 Nov;10(4):553-61.
"I wish I had seen this test result earlier!": Dissatisfaction with test-result management systems in primary care. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. Arch Inter Med. 2004 Nov 8;164:2223-8.
Effect of reducing interns' work hours on serious medical errors in intensive care units.
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R,, Burdick E, Katz JT, Lilly CM, Stone PH, Lockely SW, Bates DW, Czeisler CA.. N Engl J Med. 2004 Oct 28;351(18):1838-48.
Using information technology to improve surgical safety. Bates DW. British Journal of Surgery 2004 Aug;91:939-40.
Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Poon EG, Blumenthal D, Jaggi T, Honour MM, Bates DW, Kaushal R. Health Aff 2004;23:184-190.
Communication factors in the follow-up of abnormal mammograms. Poon EG, Haas JS, Puopolo AL, Gandhi TK, Burdick E, Bates DW, Brennan TA. J Gen Intern Med. 2004 Apr;19(4):316-23.
Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH, Harvard Medical Practice Study I. Qual Saf Health Care. 2004 Apr;13(2):145-51:discussion 151-2.
Shuttling toward a safety culture. Healthcare can learn from probe panel's findings on the Columbia disaster. Frankel A, Haraden C. Mod Healtc. 2004 Jan 5;34(1):21.
Improving patient safety across a large integrated health care delivery system. Frankel A, Gandhi TK, Bates DW. Int J Qual Health Care. 2003 Dec;15 Suppl 1:i31-40.
Safety of patients isolated for infection control. Stelfox HT, Bates DW, Redelmeier DA. JAMA 2003 Oct 8;290(14);1899-905.
The godfather of patient safety sees progress. Interview by Mark Crane. Med Econ. 2003 Aug 8;80(15):29-30,33-4.
What do we know about medication errors in inpatient psychiatry? Grasso BC, Rothschild JM, Genest R, Bates DW. Jt Comm J Qual Saf. 2003 Aug;29(8):391-400.
Seeing error through new lenses. Weingart SN. J Gen Intern Med. 2003 Aug;18(8):675-6. Full text.
Is it defensible to use volume standards for purchasing care? Leape LL. Annals of Surgery 2003 Aug;238(2):168-9.
Electronically screening discharge summaries for adverse medical events. Murff HJ, Forster AJ, Peterson JF, Fiskio JM, Heiman HL, Bates DW. J Am Med Inform Assoc. 2003 Jul-Aug;10(4):339-50.
Improving safety with information technology. Bates DW , Gawande AA. N Engl J Med. 2003 Jun 19;348(25):2526-34.
Effects of computerized physician order entry and clinical decision support systems on medication safety. Kausal R, Shojania K, Bates D. Archives of Internal Medicine 2003 Jun;163(12):1409-16.
Linking laboratory and pharmacy: opportunities for reducing errors and improving care. Schiff GD, Klass D, Peterson J, Shah G, Bates DW. Arch Intern Med. 2003 Apr 28;163(8):893-900.
A cost-benefit analysis of electronic medical records in primary care. Wang SJ, Middleton B, Prosser LA, Bardon CG, Spurr CD, Carchidi PJ, Kittler AF, Goldszer RC, Failrchild DG, Sussman AJ, Kuperman GJ, Bates DW. Am J Med. 2003 Apr 1;114(5):397-403.
Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F, Goldmann DA, Bates DW. Pediatrics. 2003 Apr;111(4 Pt 1):722-9.
Multifaceted approach to reducing preventable adverse drug events. Silverman JB, Stapinski CD, Churchill WW, Neppl C, Bates DW, Gandhi TK. Am J Health Sys Pharm. 2003 Mar15;60(6):582-6.
Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Gurwitz JH, Field TS, Harold LR, Rothschild J, Debellis K, Seger AC, Cadoret C, Fish LS, Garber L, Kelleher M, Bates DW. JAMA 2003 Mar 5;289(9):1107-16.
The incidence and severity of adverse events affecting patients after discharge from the hospital. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003 Feb 4;138(3):161-7.
A proposal for electronic medical records in U. S. primary care. Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. J AM Med Inform Assoc 2003 Jan-Feb;10(1):1-10.
Patient Safety Leadership WalkRounds. Frankel A, Graydon-Baker E, Neppl C, Simmonds T, Gustafson M, Gandhi TK. Jt Comm J Qual Saf 2003 Jan;29(1):16-26.
Adherence to practice guidelines: The role of speciality society guidelines. Leape LL, Weissman JS, Schneider EC, Piana RN, Gatsonis C, Epstein AM. Am Heart J. 2003 Jan;145(1):19-26.
Analysis of medication-related malpractice claims: causes, preventability, and costs. Rothschild JM, Federico FA, Gandhi TK, Kaushal R, Williams DH, Bates DW. Arch Intern Med. 2002 Nov 25;162(21):2414-20.
Reporting of adverse events. Leape LL. N Engl J Med. 2002 Nov 14;347(20):1633-8.
Information technology and medication safety: what is the benefit? Kaushal R, Bates DW. Qual Saf Health Care. 2002 Sep;11(3):261-5.
What practices will most improve safety?: Evidence-based medicine meets patient safety [Controversies]. Leape LL, Berwick DM, Bates DW. JAMA 2002 Jul; 288(4):501-7.
Medication errors and adverse drug events in pediatric inpatients. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. JAMA. 2001 Apr 25;285(16):2114-20.
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Bates DW, Leape L, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger D. JAMA 1998;280(15):1311-1316.
Incidence of adverse drug events and potential adverse drug events: Implications for prevention. ADE Prevention Study Group. Bates DW, Cullen DL, Laird N, Peterson LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al. JAMA 1995 Jul;274(1):29-34.
Computerized physician order entry and quality of care. Bates DW, Kuperman G, Teich JM. Qual Manag Health Care 1994;2(4):18-27.
