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In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.
Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs has been challenging.
Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.
Tamayo-Sarver J. Fast Company. March 13, 2023.
Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.
Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022.
A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.