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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.
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.
Jukkala AM, Kirby RS. MCN Am J Matern Child Nurs. 2009;34:365-371.
This survey of rural hospitals in the southern United States found that hospitals with fewer than 125 deliveries per year were relatively less prepared to administer neonatal resuscitation. As well, one-third of hospitals did not have an established method for transferring patients to tertiary care hospitals.
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.
Stein R; USP; United States Pharmacopeia
This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.
An unclear verbal order leads to administration of the wrong drug.
A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.