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Taenzer AH, Pyke JB, McGrath SP. Anesthesiology. 2011;115:421-431.
Taenzer AH ; Pyke JB ; McGrath SP.A review of current and emerging approaches to address failure-to-rescue. Anesthesiology. 2011; 115: 421-431
Describing failure to rescue as a key area for improvement in patient safety, this piece reviews efforts to reduce its incidence, including rapid response teams and early warning scoring systems.
Managing alarm systems for quality and safety in the hospital setting.
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.
Johnston M, Arora S, King D, Stroman L, Darzi A. Surgery. 2014;155:989-994.
Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit.
Young-Xu Y, Fore AM, Metcalf A, Payne K, Neily J, Sculli GL. Am J Nurs. 2013;113:51-57.
A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.
Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. Pediatrics. 2013;131:e1970-e1973.
Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.
Nair BG, Peterson GN, Newman S, Wu W, Kolios-Morris V, Schwid HA. Jt Comm J Qual Patient Saf. 2012:38;283-288.
Rapid response teams and failure to rescue: one community's experience.
Hammer JA, Jones TL, Brown SA. J Nurs Care Qual. 2012;27:352-358.
Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.
Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Reducing alarm hazards: selection and implementation of alarm notification systems.
Gee T, Moorman BA. Patient Saf Qual Healthc. March/April 2011;8:14-17.
Patient alarms often unheard, unheeded.
Kowalczyk L. Boston Globe. February 13–14, 2011.
Preventing maternal death.
Sentinel Event Alert. January 26, 2010;(44):1-4.
The wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery.
Schmid F, Goepfert MS, Kuhnt D, et al. Anesth Analg. 2011;112:78-83.
Beware of basal opioid infusions with PCA therapy.
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.
Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. J Am Med Inform Assoc. 2009;16:66-71.
Using an automated risk assessment report to identify patients at risk for clinical deterioration.
Whittington J, White R, Haig KM, Slock M. Jt Comm J Qual Patient Saf. 2007;33:569-574.
Have you M.E.T. the future of better patient safety?
Larson L. Trustee. September 2005;58:6-10.
Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.
Graham AJ, Ocampo W, Southern DA, et al. BMJ Qual Saf. 2019;28:310-316
Rapid Response Systems
Solving alarm fatigue with smartphone technology.
Short K, Chung YJ Jr. Nursing. 2019;49:52-57.
Using electronic health records to identify adverse drug events in ambulatory care: a systematic review.
Feng C, Le D, McCoy AB. Appl Clin Inform. 2019;10:123-128.
Reasons for repeat rapid response team calls, and associations with in-hospital mortality.
Chalwin R, Giles L, Salter A, Eaton V, Kapitola K, Karnon J. Jt Comm Qual Patient Saf. 2019;45:268–275.
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Classen D, Li M, Miller S, Ladner D. Health Aff (Millwood). 2018;37:1805-1812.
Application of electronic trigger tools to identify targets for improving diagnostic safety.
Murphy DR, Meyer AN, Sittig DF, Meeks DW, Thomas EJ, Singh H. BMJ Qual Saf. 2019;28:151-159.
Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.
ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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