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Cases & Commentaries
- Web M&M
D. John Doyle, MD, PhD ; July-August 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
Journal Article > Study
Kane BG, Bond WF, Worrilow CC, Richardson DM, on behalf of the Lehigh Valley Hospital Airway Task Force. J Patient Saf. 2006;2:154-161.
The authors describe the development of an airway management process that includes training, airway management protocols, and a standardized airway equipment cart.
Journal Article > Commentary
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
High-reliability organizations (eg, the aviation industry) have developed methods for achieving safety despite hazardous conditions. This study describes the development of a framework to achieve high reliability in the intensive care unit (ICU) context and discusses its application to the problem of preventing catheter-related bloodstream infections. The framework is based on a previously published method for evaluating safety interventions; the key elements include selecting measurable outcomes, applying evidence-based interventions, ensuring the intervention reaches all patients, and improving the overall culture of safety. The investigators applied this approach in ICUs in Michigan and achieved significant reductions in the incidence of catheter-related bloodstream infections.