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Cases & Commentaries
- Web M&M
Bernard Lo, MD; September 2006
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.
Perspectives on Safety > Interview
Not Paying for Errors: A Policy Perspective, October 2008
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
Harmon KT. Patient Safety & Quality Healthcare. March/April 2006;3:20-26.
The author, a former flight surgeon, describes safety concepts and guidelines that have minimized mishaps in naval aviation and discusses how these may be applied to health care.
Journal Article > Study
Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.
Diagnostic errors are a known threat to patient safety, and measuring their prevalence is challenging, particularly outside pathology and radiology settings. Past studies have highlighted classification systems and related prevention strategies, including the adoption of checklists. This study explored the use of a situational awareness (SA) framework to understand diagnostic errors in a primary care setting. Investigators interviewed providers involved in a diagnostic error and revealed that one level of SA was lacking (e.g., information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels). The authors found that applying the SA framework to analyze such errors provided deeper insight into the provider–work system interaction, which included important interface with the electronic health record. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.
Journal Article > Study
Increasing compliance with the World Health Organization surgical safety checklist—a regional health system's experience.
Gitelis ME, Kaczynski A, Shear T, et al. Am J Surg. 2017;214:7-13.
The World Health Organization Surgical Safety Checklist has been widely adopted. This pre–post study examined adherence to the checklist following its integration into the electronic health record. Direct observation demonstrated increased use of the checklist in electronic form from under 50% in paper form to over 90% once integrated into the electronic health record. The authors conclude that electronic health record integration increased the implementation of an evidence-based strategy.
Journal Article > Commentary
Lo HY, Mullan PC, Lye C, Gordon M, Patel B, Vachani J. BMJ Qual Improv Rep. 2016;5:u212920.w5661.
Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.