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Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.

Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.
Washington State Hospital Association; WSHA
This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.