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- Communication Improvement 1
- Culture of Safety 3
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- Human Factors Engineering 2
- Legal and Policy Approaches 5
- Logistical Approaches 3
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches 1
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Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.
Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.
This article reports on criminal charges brought against a nurse after she committed a medication error.
Journal Article > Commentary
Philipsen NC. J Nurse Pract. 2011;7:719-726.
This commentary describes how treating medical mistakes in a punitive manner could have a detrimental effect on safe nursing practice and learning from error.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Journal Article > Study
Griffiths P, Maruotti A, Recio Saucedo A, et al; Missed Care Study Group. BMJ Qual Saf. 2019;28:609-617.
There is a clear link between nurse staffing ratios and patient safety. This study corroborates the finding that lower registered nurse staffing and higher numbers of patients admitted per nurse are associated with increased rates of in-hospital mortality. The results underscore the importance of adequate nursing to ensure safe acute care.
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.