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- Care Coordination(1)
- Communication Improvement(34)
- Computerized Decision Support(5)
- Computerized Provider Order Entry (CPOE)(5)
- Culture of Safety(22)
- Education and Training(30)
- Error Reporting and Analysis(23)
- Human Factors Engineering(36)
- Legal and Policy Approaches(11)
- Logistical Approaches(7)
- Policies and Operations(5)
- Quality Improvement Strategies(137)
- Research Directions(2)
- Specialization of Care(12)
- Technologic Approaches(13)
- Transparency and Accountability(2)
- Alert fatigue(1)
- Device-Related Complications(8)
- Diagnostic Errors(14)
- Discontinuities, Gaps, and Hand-Off Problems(17)
- Failure to rescue(2)
- Fatigue and Sleep Deprivation(1)
- Identification Errors(6)
- Inpatient suicide(1)
- Interruptions and distractions(1)
- Medical Complications(21)
- Medication Safety(31)
- MRI safety(1)
- Nonsurgical Procedural Complications(12)
- Psychological and Social Complications(8)
- Second victims(1)
- Surgical Complications(29)
- Transfusion Complications(1)
A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated.
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.
This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.
Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.
ISMP Medication Safety Alert! Acute care edition. February 10, 2022:27(3):1-6.
Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.
ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.