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Cases & Commentaries
- Web M&M
Emanuel Kanal, MD; May 2019
After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.
Award > Award Recipient
Sentara Norfolk General Hospital: accelerating improvement by focusing on building a culture of safety.
Yates GR, Hochman RF, Sayles SM, Stockmeier CA. Jt Comm J Qual Saf. 2004;30:534-542.
This hospital received national recognition for their incentive programs and leadership engagement, and for successfully balancing a culture that supports a "just" approach to error without avoiding accountability. The application of Red Rules, a stop-the-line philosophy, and simplification of administrative barriers helped them achieve an environment that supports safety and learning.
Weinstock M. Hosp Health Netw. 2007;81:38-40, 42, 44-46.
ISMP Medication Safety Alert! Acute Care Edition. April 24, 2008;13:1-3.
This article provides a set of criteria for health care professionals to develop and implement red rules as an effective risk reduction strategy.
Journal Article > Study
Rowlands A, Steeves R. AORN J. 2010;92:410-419.
Preventing surgical instruments from being retained in the patient after surgery has traditionally relied on nurses manually counting instruments used during the procedure. However, this method is not foolproof, and this qualitative study used interviews with operating room personnel to explore reasons for incorrect instrument counts. Not surprisingly, the issues identified are known contributors to safety issues in the operating room, including production pressures, poor communication between physicians and nurses, and overt disruptive behavior. In light of these findings, the authors argue that addressing the persistent problem of retained surgical instruments will require an improvement approach based on safety culture principles.