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Cases & Commentaries
- Web M&M
Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Journal Article > Study
Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool.
Bereknyei Merrell S, Gaba DM, Agarwala AV, et al. Jt Comm J Qual Patient Saf. 2018;44:477-484.
Emergency manuals have been adopted from high reliability industries as a cognitive aid for guiding interprofessional teams during clinical crises. Investigators interviewed emergency manual users after an intraoperative cardiac arrest and conceptualized how the manual helped provide optimal care. A PSNet interview reviews more broadly how to achieve high reliability in health care.