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- Communication Improvement 1
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Patient Safety Primers
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
Journal Article > Study
Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J. J Gen Intern Med. 2006;21:165-170.
This descriptive study analyzed nearly 100,000 reports from 26 acute care hospitals with investigators discovering wide variations in reporting rates across sites. The most common classification included medication-related events, and more than half of all events affected a patient before being caught. The authors report that nurses were the most frequent users of the electronic reporting systems, whereas physicians accounted for an overwhelming minority. A past study found similar underuse of reporting systems by physicians and recommended alternative methods for capturing physician-based information about adverse events.
Journal Article > Study
Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.
Maragakis LL, Bradley KL, Song X, et al. Infect Control Hosp Epidemiol. 2006;27:67-70.
The authors report an increased infection rate due to the implementation of a new technology in one U.S. hospital.
Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Johnson AM. Edinburgh, Scotland: Scottish Executive; 2006.
This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.
Journal Article > Review
Hwang RW, Herndon JH. Clin Orthop Relat Res. 2007;457:21-34.
The authors discuss the financial incentives of improving patient outcomes as the business case for patient safety.
Peskin SM. New York Times. October 4, 2018.
Error disclosures are difficult but important conversations that can have negative consequences for patients, clinicians, and organizations, even when they are done appropriately. This newspaper article offers insights from a doctor who experienced both sides of disclosure, as a physician disclosing an error and as a patient whose physician missed a complication, and discusses how to manage relationships once clinical mistakes are recognized.