Vijayakumar S, Duggar WN, Packianathan S, et al. Front Oncol. 2019;9:302.
Huddles are increasingly being used to improve safety in hospitals. This commentary describes how one hospital implemented structured multidisciplinary prospective peer review of radiation oncology patient treatment plans to help prevent harm and reduce errors. The authors discuss safety culture and minimizing clinical hierarchy as drivers of success.
Kalisch BJ, McLaughlin M, Dabney BW. Jt Comm J Qual Patient Saf. 2012;38:161-7.
Missed nursing care (failure to perform required patient care elements) is surprisingly common. This qualitative study found that patients were able to reliably identify episodes of missed nursing care and their perceptions correlated with nurses' opinions.
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.
A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
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