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Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Harmon KT. Patient Safety & Quality Healthcare. March/April 2006;3:20-26.
The author, a former flight surgeon, describes safety concepts and guidelines that have minimized mishaps in naval aviation and discusses how these may be applied to health care.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
Journal Article > Commentary
Kennerly D, Richter KM, Good V, Compton J, Ballard DJ. Am J Med Qual. 2011;26:43-52.
This commentary describes a process structured around improving safety culture and promoting use of technology to enhance patient safety.
Journal Article > Study
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.
Implementing a comprehensive safety program, which included teamwork training, additional staffing and reduction of work hours, electronic medical records, and a dedicated patient safety nurse, was associated with a sharp reduction in malpractice lawsuits and sentinel events at an academic hospital.