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- Communication Improvement 1
- Culture of Safety 2
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Quality Improvement Strategies 3
- Specialization of Care 1
- Technologic Approaches 1
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 5
- Medication Safety 2
- Surgical Complications 1
Search results for "Audiovisual"
- Critical Care
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.
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.
Tampa, FL: Sepsis Alliance; 2010.
Revealing incidents in which diagnostic delay led to sepsis, this video provides information to help consumers recognize the condition.
Luby R. KETV. Omaha, NE. March 31, 2010.
This news piece focuses on a heparin overdose that resulted in the death of a toddler.
Audiovisual > Image/Poster
Donaldson N, Shapiro S, Scott M, Foley M, Spetz J. J Nurs Adm. 2009;39:176-181.
Rapid response teams (RRTs) have proven to be very popular among bedside nursing staff, contributing to their widespread implementation despite equivocal evidence of clinical benefits. This study carried out interviews with nurses, chief nursing officers, and RRT members at 18 hospitals to obtain insights on how to successfully implement RRTs. Themes that predicted successful implementation included clear organizational support for the RRT, support for bedside nurses when the team is called, and less resistance from physicians to using the RRT.
The Oprah Winfrey Show. March 10, 2009.
This feature spotlights Dennis Quaid's experience with medical errors and offers tips for patients on protecting their health.
Inflammation and the Host Response to Injury, a Large-Scale Collaborative Project: patient-oriented research core—standard operating procedures for clinical care. II. Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient.
Minei JP, Nathens AB, West M, et al. J Trauma. 2006;60:1106-1113.
The investigators used existing data and guidelines to develop this standard operating procedure for the diagnosis and treatment of ventilator-associated pneumonia.
Audiovisual > Image/Poster
Brandwijk M, Nemeth C, O'Conner M, Kahana M, Cook RI. Departments of Pediatrics and Anesthesia and Critical Care: Chicago, IL: University of Chicago.
A recap of ongoing research studying the important transitions, or "handoffs" of care, that occur between shifts in a pediatric intensive care unit.