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- Communication Improvement 3
- Culture of Safety 3
- Education and Training 6
- Error Reporting and Analysis 3
- Human Factors Engineering 10
- Legal and Policy Approaches 3
- Policies and Operations 1
- Quality Improvement Strategies 6
- Teamwork 1
- Device-related Complications
- Diagnostic Errors 1
- Medical Complications 7
- Medication Errors/Preventable Adverse Drug Events 2
- Nonsurgical Procedural Complications 2
- Surgical Complications 3
Search results for "Audiovisual"
- Device-related Complications
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. Vox. October 23, 2017.
Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.
The near elimination of central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. Although the checklist for CLABSI prevention has been widely publicized, equally important components of the intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety culture in participating ICUs. The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success of the Michigan initiative nationwide, centered around implementation of the CUSP. The initial results, presented in this press release, indicate another remarkable success, with CLABSI rates being reduced by 40% across 1100 participating ICUs. It is notable that these reductions were accomplished even though the baseline rate of CLABSI was already lower than in prior studies. The developer of CUSP, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M in 2010.
McFadden M. WNDU. February 21, 2012.
This news video reports on a death from patient-controlled analgesia and how graphic design students were consequently inspired to design materials to enhance awareness of pain-pump safety.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Moss-Coane M, O'Connell K, Fishman N. Radio Times. April 28, 2011.
This radio program featured interviews with an infectious disease specialist and a patient who contracted a hospital-acquired infection, and discussed how patients and providers can reduce their occurrence.
Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.
The landmark Keystone ICU project, a statewide quality improvement initiative that used interventions grounded in safety culture and human factors engineering to improve safety in the intensive care unit, stands as one of the seminal achievements of the patient safety field. The success of the Keystone ICU project at reducing central line–associated bloodstream infections has been widely publicized, and this study reports a similar success in reducing rates of ventilator-associated pneumonia. As with the prior results, this article emphasizes that the success of the study was attributable to the multifaceted quality improvement approach used and the cultural change it engendered in participating ICUs.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; July 2018.
This report compiles patient safety data documented by Massachusetts hospitals. The latest numbers represent a modest decrease in serious reportable events recorded in acute care hospitals, from 1012 the previous year to 922. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.
Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.
Audiovisual > Audiovisual Presentation
Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.
This collection of video segments offers information on common types of medical errors, particularly medication errors, based on reports to the Institute for Safe Medication Practices.
Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.
This video segment warns about potential dosing errors for an epileptic seizure treatment due to equipment design and provides instructions to minimize user error.
Food and Drug Administration (FDA) Patient Safety News. Show #57. November 2006.
This video news segment recaps concerns over the use of an infusion pump with an identified design defect.
Shah JS, Maisel WH. JAMA. 2006;296:655-660.
The authors analyzed recall and safety alerts for automated external defibrillators and found that advisories occur frequently, and actual malfunctions occur occasionally.