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Cases & Commentaries
- Web M&M
D. John Doyle, MD, PhD ; July-August 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
Tools/Toolkit > Government Resource
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
Tools/Toolkit > Toolkit
Denver, CO: Denver Health; 2007.
Part of the AHRQ-funded PIPS program, this module provides educational materials for health care workers regarding teamwork and communication.
Federico F, Bonacum D. Healthc Exec. January/February 2010;25:68-70.
This piece outlines steps such as training and senior leader support that can help enhance the role of middle managers in patient safety and quality improvement.
Web Resource > Multi-use Website
Society for Simulation in Healthcare.
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials for an annual campaign to raise awareness of professionals that use simulation to develop teamwork, communication, and crisis management skills in health care. The 2019 observance will be held September 16–20.