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Special or Theme Issue
Special Issue: Patient Safety.
Ergonomics. 2006;49:439-630.
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Patient Safety Primers
Falls
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 > Review
A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.
Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.
Interventions intended to enhance patient safety may have unanticipated consequences. This systematic review found that unintended consequences of patient safety interventions, positive and negative, are common. Researchers recommend that all patient safety interventions should be monitored for these unexpected outcomes.
Book/Report
Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.
Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.
Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.
Cases & Commentaries
Falling Through the Crack (in the Bedrails)
- Spotlight Case
- CME/CEU
- Web M&M
Patricia C. Dykes, PhD, RN; Wai Yin Leung, MS; and Vincent Vacca, RN, MSN; May 2016
Multiple alarms went off in an ICU room after an intern and resident performed paracentesis on an older patient. Nurses found the patient confused and trying to get out of bed. She had pulled out her nasogastric and endotracheal tubes, her leg was stuck in the bedrails, and she had a large cut on her foot.
Journal Article > Commentary
Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.
Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.
Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.
Cases & Commentaries
Medical Devices in the "Wild"
- Web M&M
Ayse P. Gurses, PhD, and Peter Doyle, PhD; December 2014
An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.
Book/Report
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2017.
This report summarizes progress in patient safety improvement in the past decade and reviews the 2016 activities of the Patient Safety Authority, including an initiative to improve the standardization of their reporting process that resulted in an increase of serious events reported and an effort that reduced health care–associated infections in nursing homes.
Journal Article > Study
The association of shift-level nurse staffing with adverse patient events.
Patrician PA, Loan L, McCarthy M, et al. J Nurs Adm. 2011;41:64-70.
In this study conducted at military hospitals, greater nursing experience and skill mix was associated with a lower incidence of falls and medication errors.
Cases & Commentaries
Dangerous Dialysis
- Spotlight Case
- Web M&M
Jean L. Holley, MD ; October 2010
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
Bibliography
Keeping Kidney Patients Safe.
Renal Physicians Association.
This Web site provides toolkits, educational modules, and an annotated bibliography to support quality improvement efforts for nephrology providers, and identifies best practice strategies for avoiding the Five Adverse Patient Safety Events in renal care.
Journal Article > Study
Adverse events and near miss reporting in the NHS.
Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.
This study evaluated the utility of a voluntary reporting system from several National Health Service trusts. Investigators collected, categorized, and analyzed anonymized data from nearly 29,000 incidents, with the largest proportion related to falls. Discussion includes detailed presentation of the frequency of events, their location of occurrence, and the low rate of incidents associated with a catastrophic outcome. The authors conclude that this type of reporting system can provide useful information on a national level but requires the development of information technology systems to support the efforts.
Cases & Commentaries
Another Fall
- Spotlight Case
- Web M&M
Sidney T. Bogardus, Jr., MD; April 2003
Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!