Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Quality Improvement Strategies
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 1
- Surgical Complications
Search results for ""
Cases & Commentaries
- Spotlight Case
- Web M&M
Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD; May 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.
Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Journal Article > Commentary
Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.
Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. J Am Coll Surg. 2012;215:453-466.
This guideline describes recommendations for preoperative assessment of elderly surgical patients, including risk factors for postoperative delirium and pulmonary complications, to enhance safety and reduce readmissions.