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- Culture of Safety 1
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Device-related Complications
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 1
- Medication Safety 2
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Journal Article > Study
Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.
Journal Article > Commentary
Burdeu G, Crawford R, van de Vreede M, McCann J. J Nurs Care Qual. 2006;21:151-159.
Investigators applied a systems approach and design concepts to improve drug infusion safety at an acute care hospital.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.