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Cases & Commentaries
- Web M&M
Jeffrey Driver, JD, MBA ; October 2004
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.
Journal Article > Study
Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals.
Travaglia JF, Westbrook MT, Braithwaite J. Health (London). 2009;13:277-296.
Physicians had a more negative view of incident reporting systems and tended to use more narrow and physician-centric descriptors when reporting an incident.