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- Communication Improvement 1
- Culture of Safety 1
- Error Reporting and Analysis 2
- Human Factors Engineering 3
- Legal and Policy Approaches 2
- Quality Improvement Strategies 3
- Teamwork 1
- Transparency and Accountability 2
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Cases & Commentaries
- Web M&M
Curtiss B. Cook, MD; January 2009
Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.
Kowalczyk L. Boston Globe. April 17, 2009;Metro:1.
This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery program following errors that caused serious complications for two infants.
Journal Article > Study
A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.
Kaufman J, Twite M, Barrett C, et al. Jt Comm J Qual Patient Saf. 2013;39:306-311.
A standardized handoff protocol for cardiac surgery patients between the operating room and intensive care unit led to decreases in unplanned extubations and the amount of time spent on ventilators.
Journal Article > Organizational Policy/Guidelines
Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.
Wahr JA, Prager RL, Abernathy JH 3rd, et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, Council on Quality of Care and Outcomes Research. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.
Journal Article > Review
Shake JG, Pronovost PJ, Whitman GJR. J Card Surg. 2013;28:406-413.
Journal Article > Commentary
FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.
Barbeito A, Lau WT, Weitzel N, Abernathy JH III, Wahr J, Mark JB. Anesth Analg. 2014;119:777-783.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.