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- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Logistical Approaches
- Quality Improvement Strategies 1
- Specialization of Care 1
- Technologic Approaches
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 2
- Interruptions and distractions 1
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 1
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Cases & Commentaries
- Web M&M
Tess Pape, PhD, RN, CNOR; February 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Perspectives on Safety > Interview
Patient Safety in Emergency Medicine, June 2010
Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.
Journal Article > Study
Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.
Conducted by the American Society of Health-System Pharmacists (ASHP), this survey of more than 1300 pharmacy directors sought to evaluate the use of safety measures targeting medication dispensing and administration errors. Some positive signs were found in that use of proven technologies such as bar coding and smart infusion pumps has increased, but the overall proportion of hospitals using these technologies remains relatively low. Only a small proportion of hospitals had pharmacists attached to the emergency department (ED) or reviewed medication orders in the ED for errors. Prior surveys by the ASHP have examined the use of safety mechanisms for preventing prescribing and transcribing errors.
Reese SM. Information Week. March 11, 2014.
This article describes how wearable technologies for clinicians can improve workload distribution, information gathering, and staffing decisions to address safety issues, particularly nurse fatigue.
Journal Article > Study
Components of hospital perioperative infrastructure can overcome the weekend effect in urgent general surgery procedures.
Kothari AN, Zapf MAC, Blackwell RH, et al. Ann Surg. 2015;262:683-691.
The weekend effect is a well-documented phenomenon where patients admitted over the weekend have inferior outcomes compared to those admitted on a weekday. This retrospective study utilized the AHRQ Healthcare Cost and Utilization Project database and found that specific factors, such as full adoption of electronic health records, home health programs, and increased nurse-to-bed ratios, were associated with overcoming the weekend effect in hospitals.
Journal Article > Commentary
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.