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Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
This special issue highlights an AHRQ-funded symposium on the role of simulation in medical education and covers topics such as teamwork training and skill improvement.
Rockville, MD: US Food and Drug Administration; November 9, 2010.
This notice analyzes findings from a government initiative on CT scan injuries and provides recommendations to enhance safety and prevent such incidents.
Grant > Government Resource
Patient Safety Learning Laboratories: Pursuing Safety in Diagnosis and Treatment at the Intersection of Design, Systems Engineering, and Health Services Research (R18).
Rockville, MD: Agency for Healthcare Research and Quality. RFA-HS-19-001.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Journal Article > Commentary
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment.
Henriksen K, Rodrick D, Grace EN, Shofer M, Brady PJ. J Patient Saf. 2019 Feb 9; [Epub ahead of print].
Applying systems engineering strategies from problem analysis through postimplementation evaluation can lead to solutions grounded in actual practice and learning for individuals, teams, and organizations. This commentary discusses the Agency for Healthcare Research and Quality patient safety learning laboratories initiative. The authors, who serve as program officers and oversee the grants, review lessons learned through experiences of grantees.