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Cases & Commentaries
- Spotlight Case
- Web M&M
Amy A. Vogelsmeier, PhD, RN; September 2011
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Journal Article > Commentary
The quality 'journey' at Ascension Health: how we've prevented at least 1,500 avoidable deaths a year—and aim to do even better.
Pryor D, Hendrich A, Henkel RJ, Beckmann JK, Tersigni AR. Health Aff (Millwood). 2011;30:604-611.
This commentary reveals how one large health care system successfully reduced preventable deaths and suggests that adopting principles from high reliability organizations can improve safety.