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Cases & Commentaries
- Web M&M
Matthew S. Russell, MD, and Marika D. Russell, MD; July/August 2015
Admitted to the hospital with sepsis and pneumonia, an elderly man developed acute respiratory distress syndrome requiring mechanical ventilation. On hospital day 12, clinicians placed a tracheostomy, and a few days later the patient developed acute hypoxia and ultimately went into cardiac arrest when his tracheostomy tube became dislodged.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.
Journal Article > Study
Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.
Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149–155.e3.
This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.
Journal Article > Commentary
Su L. Curr Probl Pediatr Adolesc Health Care. 2015;45:367-369.
Efforts to understand the nature of human error can enhance care safety. Discussing the potential for unexpected human behaviors during crises to result in failure, this commentary reveals how insights drawn from video analysis of teams in critical situations informed adjustments to training to reduce risks in cardiac care.