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Cases & Commentaries
- Web M&M
Nancy Spector, PhD, RN ; March 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
Journal Article > Commentary
Henneman EA, Gawlinski A, Giuliano KK. Crit Care Nurse. 2012;32:e9-e18.
This commentary describes how surveillance can prevent adverse events and medical errors in critical care.
Journal Article > Study
Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.
Hatch LD, Rivard M, Bolton J, et al. Jt Comm J Qual Patient Saf. 2019;45:295–303.
The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.