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McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46:341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Frush KS, Hohenhaus SM eds. Clin Pediatr Emerg Med. 2006;7(4):213-283.
This special issue provides 11 articles on various aspects of ensuring safety in pediatric emergency care, including the use of rapid response teams and family involvement in care.
Mistry KP, Turi J, Hueckel RM, et al. Clin Pediatr Emerg Med. 2006;7.
The authors discuss the implementation of a rapid response team for pediatric patient care and introduce the concept of a team that proactively monitors patients at risk of clinical deterioration rather than waiting to assess the patient when they have been alerted to a problem.