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Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.
Institute for Healthcare Improvement. March 13 - April 23, 2024.
Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.
This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with rapid clinical deterioration and eventual demise. The patient’s ascitic fluid cultures and autopsy findings confirmed bowel perforation, but this diagnosis was never explicitly considered.
Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.
Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472.
During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.1
Collaborative for Accountability and Improvement. January 26, 2023.