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- Communication Improvement 2
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 5
- Human Factors Engineering 7
- Legal and Policy Approaches 2
- Quality Improvement Strategies 6
- Technologic Approaches 1
- Device-related Complications
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 7
- Medication Safety 3
- Surgical Complications 4
Search results for "Newspaper/Magazine Article"
- Newspaper/Magazine Article
- Indwelling Tubes and Catheters
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 616 reported latex-related events, this investigation found that more than half of the incidents were associated with indwelling urinary catheter use. Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation of patient allergies are possible risk reduction strategies. A WebM&M commentary discussed allergy documentation in patient health records.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.
Levine H. Consum Rep. 2017 Jan;82:32-40.
Hospital rating systems have yet to receive approval across the health care industry, but they still serve as a way for consumers to select hospitals and providers. This news article reports on publicly available data for central line infections in hospitals across the United States and spotlights checklists as a strategy that contributes to improvement. The article also ranks teaching hospitals based on their performance at preventing central line infections.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Vockley M. Joint Commission: The Source. June 2012;10:15-17.
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.
Harasim P. Las Vegas Review-Journal. November 21, 2010;News:1B.
This article discusses how the organizational system of one hospital delayed an investigation into catheter line malfunctions.
Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.
This newsletter piece describes a strategy for health care leaders to gain frontline insight and knowledge of evidence-based patient safety improvement tactics in their organizations.
Harris G. New York Times. August 21, 2010:A1.
This article describes documented look-alike issues with medical equipment that have yet to be addressed by federal regulation.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Consumer Reports. March 2010;75:16-21.
Tremlett G. Guardian.co.uk; July 13, 2009.
This newspaper article reports on a family that experienced two medical errors, resulting in the death of both a mother and her infant.
Landro L. Wall Street Journal. June 27, 2007:D3.
This article discusses errors associated with tubing misconnections in hospital-based care. A previous WebM&M commentary discussed a tubing error that led to administration of the wrong gas.
Sentinel Event Alert. April 3, 2006;(36):1-3.
This alert summarizes types of tubing misconnections reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and recommends 10 strategies to prevent their occurrence.
Berwick DM. Newsweek. December 12, 2005;46:75-78.
Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K Lives Campaign.
Szabo L. USA Today. August 23, 2005.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).