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Cases & Commentaries
- Spotlight Case
- Web M&M
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
Journal Article > Commentary
Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.
Hearns S, Shirley PJ. Emerg Med J. 2006;23:943-947.
The authors describe the retrieval and transfer of critically ill patients from one environment to another and provide recommendations for making this process as safe and reliable as possible.
Journal Article > Study
Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-661.
Implementation of structured processes improved emergency department communication in two areas: communication between paramedics and emergency department staff, and documentation of the patient's initial clinical condition by physicians.
Journal Article > Study
'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-736.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.