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- Error Reporting and Analysis 10
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- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 3
- Device-related Complications 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 4
- Medical Complications 8
- Medication Safety 8
- Nonsurgical Procedural Complications 4
- Psychological and Social Complications 1
- Second victims 1
- Surgical Complications 12
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- North America 28
Search results for "Audiovisual"
- General Hospitals
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Livingston E, Howell EA. JAMA Clinical Reviews. April 2, 2019.
Maternal mortality in the United States is gaining increased attention as a patient safety concern. This podcast discusses conditions known to challenge maternal safety, the high incidence of preventable harm in this population, and care bundles as an improvement strategy. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.
Montagne R. Weekend Edition Sunday. National Public Radio. March 11, 2018.
Maternal death is a sentinel event. This news audio segment reports on childbirth-related death in the United States and firsthand accounts of complications associated with childbirth, such as infection. The interview also discusses how misdiagnosis contributes to the severity of problems. This piece is part of an ongoing series on the safety of maternal care.
Lantz F. WBUR. August 15, 2017.
Partnerships between physicians and patients can yield important outcomes that support safety improvements. This radio segment reports insights from both the patient and clinician involved in an adverse event and how this incident launched an organization that focuses on support for patients and clinicians that have been affected by medical errors.
Silverman L. Morning Edition. National Public Radio. June 9, 2014.
This radio segment discusses the experience of a pediatric medical center that hired pharmacists for its emergency department to review medication orders before the medicine is dispensed and administered in an effort to prevent medication errors.
Burcham K. WSOC-TV. November 22, 2013.
This news piece reports on a missed diagnosis of meningitis and illustrates how premature closure can hinder safe care.
Audiovisual > Commentary
Harden CS. Aesthet Surg J. 2013;33:443-448.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.
Some of the most prominent successes in the patient safety field have been achieved in preventing health care–associated infections. Sponsored by The Joint Commission Center for Transforming Healthcare and the American College of Surgeons, this effort used rigorous quality improvement methodology and a collaborative approach across seven participating hospitals to tackle the problem of surgical site infections (SSIs) in patients undergoing colorectal surgery. The project was a remarkable success, achieving a 32% reduction in SSIs during the study period. The Center for Transforming Healthcare is also sponsoring efforts to prevent wrong-site surgery and improve hand hygiene and handoff communications.
Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.
The near elimination of central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) in Michigan stands as one of the landmark accomplishments of the patient safety field. Although the checklist for CLABSI prevention has been widely publicized, equally important components of the intervention included the comprehensive unit-based safety program (CUSP) and interventions to improve safety culture in participating ICUs. The Agency for Healthcare Research and Quality subsequently sponsored an effort to extend the success of the Michigan initiative nationwide, centered around implementation of the CUSP. The initial results, presented in this press release, indicate another remarkable success, with CLABSI rates being reduced by 40% across 1100 participating ICUs. It is notable that these reductions were accomplished even though the baseline rate of CLABSI was already lower than in prior studies. The developer of CUSP, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M in 2010.
Audiovisual > Slideset
Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends.
Schneider EB, Hirani SA, Hambridge HL, et al. J Surg Res. 2012;177:295-300.
Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.
This video presents a tool designed to help prevent wrong-site surgery and improve safety in hospitals.
Maminta J. News 8 WTNH. February 3, 2012.
This news video highlights one hospital's effort to improve teamwork and communication in surgery to prevent errors.
Hopperstad J. KCPQ-TV. December 5, 2011.
This news feature reports on an incident of surgical fire and its impact on the patient.
Woodall A. Oakland Tribune. September 27, 2011.
This newspaper article reports how a medical error, which occurred during a nursing strike, resulted in a patient's death.
Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.
Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.
The landmark Keystone ICU project, a statewide quality improvement initiative that used interventions grounded in safety culture and human factors engineering to improve safety in the intensive care unit, stands as one of the seminal achievements of the patient safety field. The success of the Keystone ICU project at reducing central line–associated bloodstream infections has been widely publicized, and this study reports a similar success in reducing rates of ventilator-associated pneumonia. As with the prior results, this article emphasizes that the success of the study was attributable to the multifaceted quality improvement approach used and the cultural change it engendered in participating ICUs.
Audiovisual > Image/Poster
Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-176.
This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.
Luby R. KETV. Omaha, NE. March 31, 2010.
This news piece focuses on a heparin overdose that resulted in the death of a toddler.
Bowser BA. PBS News Hour. February 8, 2010.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.