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Journal Article > Review
Littlewood KE. Best Pract Res Clin Anaesthesiol. 2011;25:473-487.
This review explores simulation as a method to identify safety issues related to team, equipment, and system performance.
Journal Article > Study
Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.
Booth CM, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Postgrad Med J. 2011;87:694-699.
The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although morbidly obese patients are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for morbidly obese patients. The challenges of caring for obese patients are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in a morbidly obese woman.
Journal Article > Study
Maslove DM, Dubin JA, Shrivats A, Lee J. Crit Care Med. 2016;44:e1021-e1030.
Vital signs remain a mainstay of monitoring for deterioration, and early identification of and rapid response to clinical deterioration is critical to preventing patient harm. This observational study used an automated technique to characterize vital sign measurement for nearly 50,000 intensive care unit stays. Investigators found that omission of vital sign recording occurred more than one third of the time. The analysis identified logically inconsistent blood pressure measurements, which suggested data-entry error. The data included a significant proportion of unusual, outlier vital sign values. Taken together, these results demonstrate important inaccuracy in vital sign documentation in the intensive care unit. The authors recommend seeking alternatives to hourly vital sign monitoring in order to optimize safety. A previous WebM&M commmentary discussed challenges in monitoring vital signs.