Narrow Results Clear All
- Culture of Safety 1
- Education and Training 5
- Error Reporting and Analysis 4
- Human Factors Engineering 5
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies
- Device-related Complications 8
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 4
- Medication Safety 1
- MRI safety 3
- Nonsurgical Procedural Complications 2
- Surgical Complications 1
- Health Care Executives and Administrators 7
Health Care Providers
- Physicians 15
- Non-Health Care Professionals 4
- Patients 1
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Cases & Commentaries
- Spotlight Case
- Web M&M
Douglas D. Brunette, MD; March 2005
The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.
PA-PSRS Patient Saf Advis. June 2005;2:19-21.
This advisory from the Pennsylvania Patient Safety Reporting System discusses 125 reports of tourniquets being inappropriately left on patients and provides strategies to reduce these occurrences.
McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.
This front page article in The New York Times reviews flying object incidents in magnetic resonance imaging (MRI) scanners. A number of dramatic cases are described (including several that were fatal), as are some of the challenges, both technological and procedural, in preventing this safety hazard.
Kanal E, Borgstede JP, Barkovich AJ, et al; American College of Radiology. Reston, VA: ACR; 2004.
This white paper combines two reports from the ACR Blue Ribbon Panel on MR Safety. Experts developed safe practice guidelines to be used by practitioners in developing magnetic resonance safety programs.
Mitka M. JAMA. 2005;294:2145, 2148.
This news story from JAMA summarizes a teleconference on magnetic resonance imaging safety and shares some of the improvement strategies suggested by experts.
ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.
This article describes problems involving the keys on infusion pumps and includes recommendations to help prevent errors when programming infusion pumps.
Sentinel Event Alert. April 3, 2006;(36):1-3.
This alert summarizes types of tubing misconnections reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and recommends 10 strategies to prevent their occurrence.
Journal Article > Commentary
Ulaner GA, Colletti PM. J Magn Reson Imaging. 2006;23:781-782.
This letter to the editor reminds radiology professionals to take extra caution in maintaining safety in magnetic resonance suites.
Journal Article > Study
Lin JJ, Dunn A, Moore C. Am J Med Qual. 2006;21:178-184.
This study discovered that nearly 75% of internal medicine residents reported difficulty in following up on test results, with almost one-half citing that the patient's condition deteriorated due to these delays. The authors describe the most commonly reported barriers to timely follow-up (eg, lack of a reminder system, too many competing demands) and discuss the need to address these system deficiencies.
PA-PSRS Patient Saf Advis. September 2006;3:1, 5-10.
This article discusses the Pennsylvania Patient Safety Reporting System (PA-PSRS) reports of skin tears and provides suggestions to help keep patients safe from this common injury.
Journal Article > Study
Kane BG, Bond WF, Worrilow CC, Richardson DM, on behalf of the Lehigh Valley Hospital Airway Task Force. J Patient Saf. 2006;2:154-161.
The authors describe the development of an airway management process that includes training, airway management protocols, and a standardized airway equipment cart.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Commentary
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
High-reliability organizations (eg, the aviation industry) have developed methods for achieving safety despite hazardous conditions. This study describes the development of a framework to achieve high reliability in the intensive care unit (ICU) context and discusses its application to the problem of preventing catheter-related bloodstream infections. The framework is based on a previously published method for evaluating safety interventions; the key elements include selecting measurable outcomes, applying evidence-based interventions, ensuring the intervention reaches all patients, and improving the overall culture of safety. The investigators applied this approach in ICUs in Michigan and achieved significant reductions in the incidence of catheter-related bloodstream infections.
Legislation/Regulation > Organizational Policy/Guidelines
ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
These guidelines explain how to examine equipment prior to administering anesthesia; the protocol includes checklists that can be used for specific equipment systems.