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1 - 20 of 41

AHA Team Training.
 

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Gubar S.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
London, UK: Parliamentary and Health Service Ombudsman; June 2014.
This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.
Kalisch BJ, Xie B. West J Nurs Res. 2014;36:875-890.
Nurse staffing ratios have been linked to patient safety issues and inpatient mortality. This review analyzes evidence on how missed nursing care contributes to adverse events and recommends future research avenues to inform staffing models.
An elderly woman with a history of dementia underwent surgical resection of new colon cancer, which relieved a bowel obstruction. She developed acute delirium postoperatively, and the team discovered they had neglected to capture her cholinesterase inhibitor patch (a medication for dementia) in the official medication reconciliation list.
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Kalisch BJ, Xie B, Dabney BW. Am J Med Qual. 2014;29:415-22.
The extent to which patient reports capture medical errors versus poor service quality remains controversial. This survey examined hospitalized patient reports and found a substantial burden of missed care. Most frequently missed were mouth care, ambulation, repositioning, bathing, and discussing tests and procedures. The study demonstrated that patients who reported pressure ulcers, medication errors, hospital-acquired infections, and intravenous line problems were more likely to also report missed nursing care. This suggests that significant errors of omission exist in current inpatient nursing practice.
Minnesota Hospital Association; MHA.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
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.
Sentinel Event Alert. 2010;44:1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.
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.