Narrow Results Clear All
- Communication Improvement 3
- Education and Training 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches
- Quality Improvement Strategies 1
- Technologic Approaches 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 5
- Identification Errors 1
- Medical Complications 2
- Medication Safety 3
- Surgical Complications
- Internal Medicine 4
- Surgery 3
- Pharmacy 1
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Cases & Commentaries
- Web M&M
B. Joseph Guglielmo, PharmD; March 2007
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
PA-PSRS Patient Saf Advis. September 2005;2:1-5.
This article draws from the reporting system in Pennsylvania to discuss lost surgical pathology specimens and recommend a systems-oriented approach to improvement.
Grant > Government Resource
AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Journal Article > Commentary
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.