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Search results for "Risk Managers"
Journal Article > Study
Effectiveness of facilitated introduction of a standard operating procedure into routine processes in the operating theatre: a controlled interrupted time series.
Morgan L, New S, Robertson E, et al. BMJ Qual Saf. 2015;24:120-127.
Standard operating procedures, or SOPs, are a key tenet of human factors engineering. This time-series analysis found that implementing SOPs in the operating room did not change either surgical process outcomes, such as adherence to the WHO surgical checklist, or clinical outcomes. These results emphasize the challenge of applying systems solutions in clinical settings.
Journal Article > Review
Alsulami Z, Conroy S, Choonara I. Arch Dis Child. 2012;97:833-837.
Double-checking of medication administration by two qualified health professionals is meant to reduce the risk of medication errors. However, prior experience with this practice has raised numerous potential problems. This systematic review examined the limited evidence base for medication administration double-checking. The majority of included studies were qualitative and consisted of asking nurses whether they felt double-checking was likely to result in fewer medication errors. Three quantitative studies showed a modest decrease in error rates. The authors found insufficient evidence to either support or refute the practice of double-checking. Despite this lack of evidence, manual double-checking has been a previously recommended strategy and has become standard policy for high-risk medications at many hospitals.
Journal Article > Commentary
A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.
Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.
This article describes a structured approach to identify and address medical risks that might arise from changes in clinical practice.
Food and Drug Administration (FDA) Patient Safety News. Show #57. November 2006.
This video news segment recaps concerns over the use of an infusion pump with an identified design defect.
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; August 29, 2006.
This news release announces a seizure of infusion pumps that have a "key bounce" defect that could result in over-infusion of medication.