Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types

Search results for "Organizational Behaviorists"

1 - 12 of 12 results
Download Selected Citations

Show: 20 | 50 | 100

Cases & Commentaries

Is the "Surgical Personality" a Threat to Patient Safety?

  • Spotlight Case
  • Web M&M

Charles L. Bosk, PhD; April 2006

Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy.

Cases & Commentaries

From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case

  • Web M&M

David E. Newman-Toker, MD, PhD; April 2013

Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.

Cases & Commentaries

The ECG Is Not Normal

  • Spotlight Case
  • Web M&M

Abigail Zuger, MD; June 2011

An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.

Cases & Commentaries

Danger in Disruption

  • Web M&M

Dorrie K. Fontaine, RN, PhD; October 2009

A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.

Cases & Commentaries

Difficult Encounters: A CMO and CNO Respond

  • Spotlight Case
  • Web M&M

Ernest J. Ring, MD; Jane E. Hirsch, RN, MS; October 2009

Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.

Cases & Commentaries

Do Not Disturb!

  • Spotlight Case
  • Web M&M

F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007

Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.

Cases & Commentaries

Production Pressures

  • Web M&M

Pascale Carayon, PhD; May 2007

On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.

Cases & Commentaries

Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality

  • Spotlight Case
  • Web M&M

Peter Lindenauer, MD, MSc; November 2006

A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.

Cases & Commentaries

It's All in the Syringe

  • Web M&M

Saul N. Weingart, MD, PhD; August 2006

In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.

Cases & Commentaries

Right? Left? Neither!

  • Spotlight Case
  • Web M&M

Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006

A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.

Cases & Commentaries

Caution, Interrupted

  • Web M&M

Robert L. Wears, MD, MS; September 2004

A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.

Cases & Commentaries

40 of K

  • Web M&M

Timothy S. Lesar, PharmD; November 2003

An unclear verbal order leads to administration of the wrong drug.

Back to Top