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- Communication Improvement
- Culture of Safety 1
- Human Factors Engineering 2
- Logistical Approaches 1
- Specialization of Care 1
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Identification Errors 1
- Medical Complications
- Medication Safety 2
- Surgical Complications 2
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Cases & Commentaries
- Web M&M
Christopher R. Lee, MD; October 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Cases & Commentaries
- Spotlight Case
- Web M&M
Emily L. Aaronson, MD, MPH, and Christopher Kabrhel, MD, MPH; May 2019
Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.
Journal Article > Commentary
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
This commentary provides background on the development of the Joint Commission's 2009 National Patient Safety Goals and summarizes the goals set for the hospital environment.
Journal Article > Study
The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.
Hess DR, Tokarczyk A, O’Malley M, Gavaghan S, Sullivan J, Schmidt U. Chest. 2010;138:1475-1479.
Teamwork and communication failures are a continued threat to patient safety. Intensive care units (ICU) have demonstrated the impact of different strategies to address these failures and improve patient outcomes. This study, targeting patients with prolonged respiratory failure, involved adding a verbal telephone report to an existing written one during transfer from the ICU. While the strengthened handoff process was associated with a trend toward reduced readmissions, its most impressive impact was on the total cost of care per patient, which fell significantly. Investigators estimated that nearly $185,000 was saved per 100 discharges, arguing that their intervention represents an improvement in the value of care (quality divided by cost) for this population. An accompanying editorial [see link below] discusses the implications of these findings and the broader role of poor communication in medical errors.
Journal Article > Review
Wolfe HA, Mack EH. Transl Pediatr. 2018;7:267-274.
Pediatric critical care patients are at greater risk for harm. This review examines how a culture of safety affects pediatric critical care delivery and highlights collaboratives as effective mechanisms to develop and test improvement strategies. The authors discuss the development of bundles to reduce hospital-acquired infections and standardize handoffs as promising safety improvement practices.