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- Communication Improvement 2
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Device-related Complications 1
- Medical Complications
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
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.