Newspaper/Magazine Article Safety shortcomings spotted in Sunrise catheter case. Citation Text: Harasim P. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL December 8, 2010 Harasim P. View more articles from the same authors. This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions. Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Harasim P. Copy Citation Related Resources From the Same Author(s) Physician accused of reusing devices has license suspended. March 30, 2011 Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professionals. September 13, 2017 Losing Laura. November 14, 2018 Patient Safety Culture: Theory, Methods and Application. January 21, 2015 Physician: 'I almost killed a patient' because of an advance directive. May 14, 2014 "Does your knee make more of a click or a clack?"; teaching "Car Talk" to new docs. March 13, 2019 The computer will see you now. August 28, 2019 What surgeons leave behind costs some patients dearly. March 20, 2013 Far more could be done to stop the deadly bacteria C. diff. August 29, 2012 The other opioid crisis: hospital shortages lead to patient pain, medical errors. March 28, 2018 When is the surgeon too old to operate? February 13, 2019 Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists. November 5, 2008 Geisinger Health System's plan to fix America's health care. October 15, 2008 Too exhausted to act safely? May 24, 2006 Generic drug names: fertile ground for errors? August 31, 2005 Engaging Patients as Safety Partners: a Guide for Reducing Errors and Improving Satisfaction. June 18, 2008 Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. February 13, 2017 Josie King Act of 2004. March 27, 2005 Complexity and the Adoption of Innovation in Health Care. March 6, 2005 Field Guide to Collaborative Care: Implementing the Future of Health Care. August 5, 2015 Preventing high-alert medication errors in hospital patients. May 27, 2015 Thinking about our thinking as physicians. October 19, 2011 Thousands of doctors practicing despite errors, misconduct. August 28, 2013 Doctors perform thousands of unnecessary surgeries. July 10, 2013 "Sully" Sullenberger takes on patient safety. September 5, 2012 Adverse Drug Events in US Hospitals, 2004. April 25, 2007 21st Century Health Information Act of 2005. May 25, 2005 Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. March 10, 2010 Navigating risks in breast cancer diagnosis and treatment. October 28, 2015 How effective are incident-reporting systems for improving patient safety? A systematic literature review. December 16, 2015 Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance. March 16, 2016 Patient Safety in Emergency Medicine. February 17, 2010 Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives. August 25, 2010 Guide for Developing a Community-Based Patient Safety Advisory Council. October 3, 2007 Judgment under Uncertainty: Heuristics and Biases. March 6, 2005 Teamwork and communication in surgical teams: implications for patient safety. January 9, 2008 Diagnosis: Interpreting the Shadows. July 26, 2017 Preventing Medication Errors: Quality Chasm Series. July 26, 2006 Patient Safety: Achieving a New Standard of Care. December 21, 2005 Patient Safety: Achieving a New Standard for Care. March 6, 2005 Human Factors and Ergonomics in Patient Safety. June 2, 2010 The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events. September 23, 2015 Promoting Safety and Quality Through Human Resource Practices: Executive Summary. August 24, 2011 Handoff Communication Tools. January 16, 2013 Guide to Patient and Family Engagement: Environmental Scan Report. June 27, 2012 Patient safety, systems design and ergonomics. June 21, 2006 Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals. June 23, 2010 Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System. November 4, 2009 Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report. November 17, 2010 Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis. January 25, 2017 Implementing and validating a comprehensive unit-based safety program. May 11, 2005 Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. February 20, 2013 A system-based approach to managing patient safety in ambulatory care (and beyond). January 10, 2018 Safe healthcare. March 6, 2005 Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. October 24, 2018 Knowledge for Improvement. April 27, 2011 Human Factors Engineering for Healthcare Applications. April 14, 2010 ASPEN Parenteral Nutrition Safety Summit. March 21, 2012 Do HSMRs really measure patient safety? August 13, 2008 To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 The COVID-19 pandemic and dentistry: parts 1 and 2. January 13, 2021 Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022 Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. June 22, 2022 Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. May 11, 2022 Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. May 5, 2010 Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. January 8, 2020 Fatigue and safety in paramedicine. December 18, 2019 Proceedings from the European Handover Research Collaborative. December 5, 2012 Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. March 22, 2023 Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future. March 15, 2023 Patient perception of fall risk and fall risk screening scores. March 15, 2023 Patient safety and the question of dignitary harms. March 15, 2023 Psychosocial working conditions as determinants of concerns to have made important medical errors and possible intermediate factors of this association among medical assistants - a cohort study. March 8, 2023 Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data. February 22, 2023 Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. February 15, 2023 Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study. September 23, 2020 Considering the safety and quality of artificial intelligence in health care. September 16, 2020 Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. September 16, 2020 State policies for prescription drug monitoring programs and adverse opioid-related hospital events. September 9, 2020 Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students. September 9, 2020 The psychological experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing. September 2, 2020 Factors associated with workarounds in barcode-assisted medication administration in hospitals. August 26, 2020 Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. August 12, 2020 Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure. August 12, 2020 Supporting the emotional well-being of health care workers during the COVID-19 pandemic. August 5, 2020 Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. May 12, 2021 Hearing impairment and the amelioration of avoidable medical error: a cross-sectional survey. April 28, 2021 Implicit bias in healthcare: clinical practice, research and decision making. April 21, 2021 The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents. April 21, 2021 SAFER Care: improving caregiver comprehension of discharge instructions. March 31, 2021 Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. March 31, 2021 Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. March 17, 2021 Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals March 10, 2021 Reaching the summit of discharge summaries: a quality improvement project. March 3, 2021 Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study. March 3, 2021 Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021 Measurement and monitoring patient safety in prehospital care: a systematic review. February 24, 2021 Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments. February 17, 2021 System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. February 10, 2021 The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making. January 27, 2021 View More Related Resources Annual Perspective Equity in Patient Safety March 27, 2024 WebM&M Cases Misconnection Leading to Arterial Thrombosis June 28, 2023 What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States. June 21, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment. April 26, 2023 Patient Safety Innovations The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023 WebM&M Cases Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023 Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. December 14, 2022 Experience of learning from everyday work in daily safety huddles: a multi-method study. September 14, 2022 Toolkit for Preventing CLABSI and CAUTI in ICUs. April 27, 2022 Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022 Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts. February 7, 2022 Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11. September 1, 2021 Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021 Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. November 4, 2020 Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study. January 29, 2020 Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. August 14, 2019 FDA to end program that hid millions of reports on faulty medical devices. May 29, 2019 Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019 Insulin pumps have most reported problems in FDA database. December 5, 2018 The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018 Report faults Children's Hospital for medication errors. June 6, 2018 Preventing newborn falls and drops. April 11, 2018 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. November 30, 2016 Misdiagnoses: a hidden risk of genetic testing. November 16, 2016 More than half a million heart surgery patients at risk of a dangerous infection. October 26, 2016 Higher quality of care and patient safety associated with better NICU work environments. September 2, 2015 A descriptive study of nurse-reported missed care in neonatal intensive care units. May 6, 2015 Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit. October 8, 2014 Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. June 4, 2014 View More See More About The Topic Intensive Care Units Patients Neonatology and Intensive Care Indwelling Tubes and Catheters Active Errors View More
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professionals. September 13, 2017
Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists. November 5, 2008
Engaging Patients as Safety Partners: a Guide for Reducing Errors and Improving Satisfaction. June 18, 2008
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. February 13, 2017
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. March 10, 2010
How effective are incident-reporting systems for improving patient safety? A systematic literature review. December 16, 2015
Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives. August 25, 2010
The Expert Panel Report to Texas Health Resources Leadership on the 2014 Ebola Events. September 23, 2015
Incorporating Health Information Technology Into Workflow Redesign: Request for Information Summary Report. November 17, 2010
Safer Delivery of Surgical Services: a Programme of Controlled Before-and-after Intervention Studies with Pre-planned Pooled Data Analysis. January 25, 2017
Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. October 24, 2018
To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021
Care transition of trauma patients: processes with articulation work before and after handoff. February 16, 2022
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. June 22, 2022
Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. May 11, 2022
Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK. May 5, 2010
Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study. January 8, 2020
Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias. March 22, 2023
Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future. March 15, 2023
Psychosocial working conditions as determinants of concerns to have made important medical errors and possible intermediate factors of this association among medical assistants - a cohort study. March 8, 2023
Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data. February 22, 2023
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. February 15, 2023
Early warning scores to predict noncritical events overnight in hospitalized medical patients: a prospective case cohort study. September 23, 2020
Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. September 16, 2020
State policies for prescription drug monitoring programs and adverse opioid-related hospital events. September 9, 2020
Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students. September 9, 2020
The psychological experience of obstetric patients and health care workers after implementation of universal SARS-CoV-2 testing. September 2, 2020
Factors associated with workarounds in barcode-assisted medication administration in hospitals. August 26, 2020
Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. August 12, 2020
Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure. August 12, 2020
Supporting the emotional well-being of health care workers during the COVID-19 pandemic. August 5, 2020
Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review. May 12, 2021
Hearing impairment and the amelioration of avoidable medical error: a cross-sectional survey. April 28, 2021
The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents. April 21, 2021
Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. March 31, 2021
Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care. March 17, 2021
Association of a Safety Program for Improving Antibiotic Use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals March 10, 2021
Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study. March 3, 2021
Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study. February 24, 2021
Measurement and monitoring patient safety in prehospital care: a systematic review. February 24, 2021
Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments. February 17, 2021
System factors affecting intraoperative risk and resilience: applying a novel integrated approach to study surgical performance and patient safety. February 10, 2021
What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: results from a national survey in the United States. June 21, 2023
Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment. April 26, 2023
Patient Safety Innovations The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023
WebM&M Cases Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023
Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. December 14, 2022
Experience of learning from everyday work in daily safety huddles: a multi-method study. September 14, 2022
Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022
Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts. February 7, 2022
Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11. September 1, 2021
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. August 11, 2021
Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study. November 4, 2020
Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study. January 29, 2020
Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit. August 14, 2019
Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. February 6, 2019
The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. July 18, 2018
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. November 30, 2016
Higher quality of care and patient safety associated with better NICU work environments. September 2, 2015
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit. October 8, 2014
Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. June 4, 2014