Narrow Results Clear All
Search results for ""
PA-PSRS Patient Saf Advis. September 2006;3:1, 5-10.
This article discusses the Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of skin tears and provides suggestions to help keep patients safe from this common injury.
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.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
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.