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Cases & Commentaries
- Web M&M
Dean Schillinger, MD; March 2004
A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.
The author, who lost his brother to medical error, reflects on his family's frustrating experience with the hospital and legal system. He proposes that the medical profession can learn valuable lessons from the engineering safety culture.
Journal Article > Commentary
Beet C, Benoit D, Bion J. Intensive Care Med. 2019;45:505-507.
This commentary discusses current challenges to safety in critical care, such as underperforming decision support, poor organizational learning, and clinician burnout. The authors envision safety improvements due to innovations in processes like wearable monitoring technology that enables rapid response activation, workflow-embedded reflective learning, and patient–clinician collaboration.