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Journal Article > Commentary
Hemingway MW, O'Malley C, Silvestri S. AORN J. 2015;101:404-415.
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Journal Article > Study
Heslin MJ, Doster BE, Daily SL, et al. J Am Coll Surg. 2008;206:1083-1089.
This study describes changes implemented at a single academic medical center to address inefficiently run systems, focusing on multidisciplinary and data-driven efforts.
Journal Article > Study
Becker DJ. Health Serv Res. 2007;42:1589-1612.
Prior research has demonstrated that patients admitted to the hospital on a weekend have a higher risk of mortality from conditions requiring emergency treatment and may experience a higher rate of preventable complications. These problems have been attributed to lower hospital staffing ratios on weekends. This article specifically evaluated the quality of care provided to patients hospitalized with acute myocardial infarction (AMI) and found that patients admitted on weekends were significantly less likely to undergo invasive treatments (such as cardiac catheterization or bypass surgery) within the first day of admission. This finding corroborates another recent study, which also found a lower rate of invasive procedure use among AMI patients admitted on the weekend, and also demonstrated increased mortality among those patients. Taken together, these results suggest that both increased staffing and incentives to perform weekend procedures may be needed to counteract the "weekend effect."