Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering
- Legal and Policy Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 4
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 1
- Medical Complications
- Medication Safety 3
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.
Cases & Commentaries
- Web M&M
Gurpreet Dhaliwal, MD; December 2009
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
Sipkoff M. Drug Topics (Health-System Edition). January 22, 2007.
This article spotlights two Philadelphia hospitals recognized for their innovative medication safety initiatives: use of color-coded storage bins and a venothromboembolism risk assessment form.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
This article explains safety challenges commonly associated with heparin, a high-alert medication, and outlines how hospitals and clinicians can prevent these errors.
Journal Article > Study
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.
Byrnes MC, Schuerer DJ, Schallom ME, et al. Crit Care Med. 2009; 37:2775-2781.
Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.
Weinstock M. Hosp Health Netw. 2011 Apr;85:46-49, 2.
This article discusses one hospital system's effort to hardwire safety into daily work by having providers look at each patient as a loved one.
Journal Article > Commentary
Saint S, Krein SL, Manojlovich M, Kowalski CP, Zawol D, Shojania KG. J Patient Saf. 2011;7:175-180.
Discussing hospital-acquired conditions and strategies for prevention, this commentary recommends assigning a hospital-based clinician to assess safety at the individual patient level.