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Cases & Commentaries
- Web M&M
Christopher R. Lee, MD; October 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Journal Article > Study
Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA. J Patient Saf. 2010;6:180-186.
This study found that a teamwork training program increased compliance with time outs, briefings, and debriefings in multiple surgical settings. Based on noted interactions between NOTECHS scores and individual sites, the authors advocate for greater attention to elements of safety culture such as organizational commitment.