Safety shortcomings spotted in Sunrise catheter case.

Newspaper/Magazine Article

Safety shortcomings spotted in Sunrise catheter case.

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

Related Resources From the Same Author(s)

Physician accused of reusing devices has license suspended.

March 30, 2011

What surgeons leave behind costs some patients dearly.

March 20, 2013

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

Thinking about our thinking as physicians.

October 19, 2011

21st Century Health Information Act of 2005.

May 25, 2005

Far more could be done to stop the deadly bacteria C. diff.

August 29, 2012

Losing Laura.

November 14, 2018

Physician: 'I almost killed a patient' because of an advance directive.

May 14, 2014

Generic drug names: fertile ground for errors?

August 31, 2005

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

Josie King Act of 2004.

March 27, 2005

Too exhausted to act safely?

May 24, 2006

The computer will see you now.

August 28, 2019

"Does your knee make more of a click or a clack?"; teaching "Car Talk" to new docs.

March 13, 2019

Complexity and the Adoption of Innovation in Health Care.

March 6, 2005

How effective are incident-reporting systems for improving patient safety? A systematic literature review.

December 16, 2015

Adverse Drug Events in US Hospitals, 2004.

April 25, 2007

RHIOs aim to transform quality of care and patient safety.

June 7, 2006

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

February 20, 2013

'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.

December 6, 2023

Medical error and vulnerable communities.

November 16, 2022

Working Americans are getting less sleep, especially those who save our lives.

November 13, 2019

The role of teamwork in the professional education of physicians: current status and assessment recommendations.

March 6, 2005

Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients.

February 3, 2016

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

January 27, 2021

Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.

February 15, 2023

Parenteral nutrition safety.

September 22, 2021

Edgeware: Insights from Complexity Science for Health Care Leaders. Second ed.

March 6, 2005

Practical Patient Safety.

October 14, 2009

Narrowing the mindware gap in medicine.

July 20, 2022

Reaching the summit of discharge summaries: a quality improvement project.

March 3, 2021

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

February 17, 2021

Fatigue and safety in paramedicine.

December 18, 2019

Medical adverse events in the US 2018 mortality data.

January 26, 2022

From mindless to mindful practice—cognitive bias and clinical decision making.

July 31, 2013

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Nonopioid directives: unintended consequences in the operating room.

June 29, 2022

Outcomes-based nurse staffing during times of crisis and beyond.

February 16, 2022

To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare.

May 5, 2021

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2.

August 12, 2020

Accuracy of pressure ulcer events in US nursing home ratings.

August 24, 2022

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations.

March 31, 2021

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

What became of the 'eyes and the ears'?: exploring the challenges to reporting poor quality of care among trainee medical staff.

August 11, 2021

Coping strategies in health care providers as second victims: a systematic review.

August 4, 2021

Understanding situation awareness in nursing work: a hybrid concept analysis.

April 4, 2012

Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety.

March 27, 2019

Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professionals.

September 13, 2017

'Care left undone' during nursing shifts: associations with workload and perceived quality of care.

August 14, 2013

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

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

Factors associated with workarounds in barcode-assisted medication administration in hospitals.

August 26, 2020

Second Annual Nursing Leadership Congress: "Building the Foundation for a Culture of Safety" conference proceedings.

June 20, 2007

Prevention Is Better Than Cure: Learning From Adverse Events in Healthcare.

May 10, 2017

WebM&M Cases

Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures

January 1, 2008

WebM&M Cases

How Do Providers Recover From Errors?

January 1, 2008

WebM&M Cases

Slippery Slide Into Life

December 1, 2005

WebM&M Cases

To LP or Not LP

October 1, 2003

WebM&M Cases

Too Many Cooks in the Kitchen

August 26, 2020

WebM&M Cases

Getting the Diagnosis Both Right and Wrong

September 25, 2019

Perspective

The Safety of Medical Devices

June 1, 2011

Preventing high-alert medication errors in hospital patients.

May 27, 2015

Field Guide to Collaborative Care: Implementing the Future of Health Care.

August 5, 2015

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

Fatigue and risk: are train drivers safer than doctors?

November 29, 2017

WebM&M Cases

Mismanagement of Delirium

May 1, 2016

Enhancing Patient Care: A Practical Guide to Improving Quality and Safety in Hospitals.

November 4, 2009

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

March 10, 2010

WebM&M Cases

The Fluidity of Diagnostic "Wet Reads"

May 1, 2016

Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives.

August 25, 2010

Patient Safety in Emergency Medicine.

February 17, 2010

First, Do No Harm: Improving Health Quality and Patient Safety.

May 18, 2011

Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance.

March 16, 2016

Navigating risks in breast cancer diagnosis and treatment.

October 28, 2015

WebM&M Cases

Hazards of Loading Doses

January 1, 2017

WebM&M Cases

Resuscitation Errors: A Shocking Problem

August 21, 2007

WebM&M Cases

Fire in the Hole!—An OR Fire

April 1, 2015

WebM&M Cases

Medical Devices in the "Wild"

December 1, 2014

WebM&M Cases

Acute Care Admission of the Behavioral Health Patient

April 1, 2013

WebM&M Cases

Privacy Gone Awry

May 1, 2004

WebM&M Cases

Crossing the Line

March 1, 2004

WebM&M Cases

Anemia and Delayed Colon Cancer Diagnosis

August 10, 2019

WebM&M Cases

Signout Fallout

February 1, 2018

Guide for Developing a Community-Based Patient Safety Advisory Council.

October 3, 2007

Perspective

What Do We Know About Emergency Department Safety?

June 1, 2010

Judgment under Uncertainty: Heuristics and Biases.

March 6, 2005

Perspective

Safety in the Prehospital Emergency Medical Services Setting

May 1, 2019

Teamwork and communication in surgical teams: implications for patient safety.

January 9, 2008

Annual Perspective

Communication During Transitions of Care

March 27, 2024

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

January 6, 2010

Diagnosis: Interpreting the Shadows.

July 26, 2017

WebM&M Cases

Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients

February 1, 2014

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

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

To make hospitals less deadly, a dose of data.

December 18, 2013

See More About The Topic

Intensive Care Units

Patients

Neonatology and Intensive Care

Indwelling Tubes and Catheters

Active Errors