Do Not Disturb!
Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
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Delay in Initiating Antibiotics Leads to Fatal Error.
Bellini LM. AHRQ WebM&M [serial online]. February 2004.
Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.
Iglehart JK. N Engl J Med. 2008;359:2633-2635.
For whom the Bell Commission tolls: unintended effects of limiting residents' hours.
Millard WB. Ann Emerg Med. 2009;54:A25-A29.
Resident fatigue: is there a patient safety issue?
Mitchell CD, Mooty CR, Dunn EL, Ramberger KC, Mangram AJ. Am J Surg. 2009;198:811-816.
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Discontinuities, Gaps, and Hand-Off Problems
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Approach to Improving Safety
Audit and Feedback
Root Cause Analysis
Communication between Providers
Duty Hour Limitation
Culture of Safety
Residents and Fellows
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