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Anesthesia Patient Safety Foundation. September 4–5, 2019; The Camby, Autograph Collection, Phoenix, AZ.
Anesthesia is a high-risk activity that has achieved safety successes. This conference will explore early recognition and rapid intervention of perioperative deterioration to avert failure to rescue. Featured speakers include Dr. Della Lin and Dr. Brad Winters.
How do nurses use early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Failure to Rescue
Interpersonal and organizational dynamics are key drivers of failure to rescue.
Smith ME, Wells E, Friese CR, Krein SL, Ghaferi AA. Health Aff (Millwood). 2018;37:1870-1976.
DeMarco P. Globe Magazine. November 3, 2018.
The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Jessica Katznelson, MD
Managing alarm systems for quality and safety in the hospital setting.
Bach TA, Berglund L, Turk E. BMJ Open Qual. 2018;7:e000202.
Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients.
Parshuram CS, Dryden-Palmer K, Farrell C, et al; Canadian Critical Care Trials Group and EPOCH Investigators. JAMA. 2018;319:1002-1012.
Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England.
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.
Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.
Importance of teamwork, communication and culture on failure-to-rescue in the elderly.
Ghaferi AA, Dimick JB. Br J Surg. 2016;103:e47-e51.
A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
Johnston MJ, Arora S, King D, et al. Surgery. 2015;157:752-763.
Preventable mortality after common urological surgery: failing to rescue?
Sammon JD, Pucheril D, Abdollah F, et al. BJU Int. 2015;115:666-674.
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.
Failure events in transition of care for surgical patients.
Helling TS, Martin LC, Martin M, Mitchell ME. J Am Coll Surg. 2014;218:723-731.
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.
Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.
Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.
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.
Failure to rescue in neonatal care.
Gephart SM, McGrath JM, Effken JA. J Perinat Neonatal Nurs. 2011;25:275-282.
A review of current and emerging approaches to address failure-to-rescue.
Taenzer AH, Pyke JB, McGrath SP. Anesthesiology. 2011;115:421-431.
Failure to rescue as a process measure to evaluate fetal safety during labor.
Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.
Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review.
Talsma A, Bahl V, Campbell DA. J Nurs Care Qual. 2008;23:202-210.
Failure-to-rescue: comparing definitions to measure quality of care.
Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Med Care. 2007;45:918-925.
Longitudinal analyses of nurse staffing and patient outcomes: more about failure to rescue.
Seago JA, Williamson A, Atwood C. J Nurs Adm. 2006;36:13-21.
Patient Safety Leadership Training & Certification Course.
Duke Center for Healthcare Safety and Quality. September 16–18, 2019; University Tower, Durham, NC.
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Aboumatar HJ, Blackledge CG Jr, Dickson C, Heitmiller E, Freischlag J, Pronovost PJ. Am J Med Qual. 2007;22:232-238.
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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