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- Communication Improvement 4
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 3
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Cases & Commentaries
- Web M&M
Edward A. Bittner, MD, PhD; February 2011
Following elective anterior cervical discectomy, a patient developed tightness and swelling in his neck. Later, the patient stood up, turned blue, and fell to the floor unconscious. An obvious neck hematoma was compromising his airway, and the patient required an emergency tracheostomy and CPR.
Association of PeriOperative Registered Nurses.
This survey will gather comments from the field regarding The Joint Commission's Universal Protocol to help eliminate wrong site surgeries.
Weinstock M. Hosp Health Netw. 2007;81:38-40, 42, 44-46.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Commentary
Larson LA, Finley JL, Gross TL, et al. Jt Comm J Qual Patient Saf. 2019:45:72-80.
Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.