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Cases & Commentaries
- Web M&M
Ayse P. Gurses, PhD, and Peter Doyle, PhD; December 2014
An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.
Perspectives on Safety > Perspective
with commentary by Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC, Designing for Safety, October 2012
This piece discusses how environmental factors contribute to adverse events in health care and describes how evidence-based design principles can improve safety.