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In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

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Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

Resilient Healthcare and the Safety-I and Safety-II Frameworks

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Perspective on Safety December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

Patient Safety Essentials for Laboratory Professionals Certificate Program.

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American Association for Clinical Chemistry; AACC.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

Patient safety and quality care.

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Nelson K. Clin Dermatol. 2014;32:542-4.

This commentary reveals insights from a physician who was involved in a misidentified specimen incident. The author explains how the organization performed a root cause analysis to determine safety gaps in specimen handling processes and recommends four key steps to prevent errors.

A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.

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Seferian EG, Jamal S, Clark K, et al. BMJ Qual Saf. 2014;23:690-7.

This quality improvement initiative used human factors approaches including failure mode and effect analysis, event review, and root cause analysis to successfully reduce the rate of specimen mislabeling in an inpatient setting. This study highlights the importance of re-examining longstanding work processes to augment safety.

Patient identification errors: the detective in the laboratory.

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Salinas M, López-Garrigós M, Lillo R, et al. Clin Biochem. 2013;46:1767-9.

Although electronic test ordering resulted in fewer patient identification errors in a clinical laboratory, significant variability in error rates between centers remained, emphasizing the continued effect of human behavior on interventions.

Are You Mrs. A? An Issue of Identification Over Telephone

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WebM&M Case October 1, 2013

After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.

The Final Check: Say it Out Loud.

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This Web site provides resources to help reduce incidence of mislabeled blood specimens based on just culture concepts.

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.

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Smith AF, Casey K, Wilson J, et al. Int J Qual Health Care. 2011;23:590-9.

Color-coded wristbands are often used to identify patients and alert providers to specific safety considerations, such as allergies. This study used human factors engineering principles to examine how wristbands were used for safety purposes at two British hospitals.

Applying the Universal Protocol to improve patient safety in radiology services.

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PA-PSRS Patient Saf Advis. June 2011;8:63-69.

Exploring causes of wrong-site, wrong patient, and wrong procedure errors in radiology, this piece suggests strategies to reduce the incidence of such events.

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

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Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

This study found a significant reduction in mislabeled blood specimens after implementing barcode technology.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.

This monthly article discusses incidents involving dosing errors and describes strategies to promote the safe use of oral syringes.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.

ISMP medication error report analysis.

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Cohen MR; Smetzer JL.

This monthly selection of error reports discusses incidents involving incomplete administration of a two-part pediatric vaccine and drug name confusion.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

ISMP medication error report analysis.

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Cohen MC. Hosp Pharm. 2009;44(5):374-378.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of reports discusses an error involving the routing of a printed label in the pharmacy, describes examples of drug name confusion, and highlights an obscure drug concentration change.

ISMP medication error report analysis.

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Cohen MR; Smetzer JL.

This monthly selection of medication error reports includes information about the risks of cutting medication patches, describes examples of drug name confusion, and explains the importance of indicating the purpose for the medication on prescriptions.

ISMP medication error report analysis.

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Smetzer JL; Cohen MR.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

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