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Cases & Commentaries
- Web M&M
José R. Maldonado, MD; October 2010
A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Hamill SD. Pittsburgh Post-Gazette. April 18, 2010:A1.
This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.
Journal Article > Study
Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.
This study reviewed 75 root cause analyses from the Veterans Health Administration system to highlight common activities during falls and frequent contributing factors. Getting up from a bed or chair was the most common activity, whereas environmental hazards and poor communication of fall risk were the most common contributing factors.
Journal Article > Commentary
Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.
Quigley PA, Barnett SD, Bulat T, Friedman Y. J Nurs Care Qual. 2014;29:51-59.
This commentary relates the experience of five hospitals that implemented different fall prevention programs and reports results of the interventions.