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Production Pressures
Carayon P. AHRQ WebM&M [serial online]. May 2007.
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Health Care Executives and Administrators
Organizational Behaviorists
Clinical Area
Anesthesiology
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Medication Errors/Preventable Adverse Drug Events
Surgical Complications
Error Types
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Scheduling Changes
Culture of Safety