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Cases & Commentaries
- Web M&M
Heather Cleland, MBBS; Jason Wasiak, BN, MPH; December 2007
After removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn.
Tools/Toolkit > Toolkit
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.
Journal Article > Study
Kho ME, Carbone JM, Lucas J, Cook DJ. Qual Saf Health Care. 2005;14:273-278.
This study examined the utility of three safety climate instruments and compared their consistency in measuring desired outcomes. Investigators administered the different tools to staff in four intensive care units and report on the test characteristics of each. The authors advocate for more rigorous evaluation of safety climate tools if they are to effectively measure the success of safety interventions in different clinical settings.
Institute for Healthcare Improvement Web site. March 20, 2006.
This article reviews the importance of medication reconciliation, discusses the difficulties of building the process into patient care, and shares stories from hospitals that have successfully implemented programs.