Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement 75
- Culture of Safety 6
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Education and Training
27
- Students 2
- Error Reporting and Analysis 18
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Human Factors Engineering
36
- Checklists 15
- Legal and Policy Approaches 9
- Logistical Approaches 16
- Quality Improvement Strategies 43
- Specialization of Care 8
- Teamwork 9
- Technologic Approaches 45
Safety Target
- Alert fatigue 4
- Device-related Complications 7
- Diagnostic Errors 18
- Discontinuities, Gaps, and Hand-Off Problems 41
- Identification Errors 13
- Interruptions and distractions 6
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Medical Complications
17
- Delirium 1
- Medication Safety 47
- Nonsurgical Procedural Complications 7
- Psychological and Social Complications 8
- Surgical Complications 21
Clinical Area
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Medicine
108
- Gynecology 27
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Internal Medicine
37
- Geriatrics 11
- Nursing 20
- Palliative Care 1
- Pharmacy 9
Target Audience
Error Types
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Active Errors
- Noncognitive Errors ("Slips & Lapses")
- Epidemiology of Errors and Adverse Events 8
- Latent Errors 38
Search results for "Noncognitive Errors ("Slips & Lapses")"
- WebM&M Cases
- Noncognitive Errors ("Slips & Lapses")
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Cases & Commentaries
Cups of Error
- Web M&M
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN; May 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Cases & Commentaries
Lap Burn
- Web M&M
Kay Ball, RN, MSA ; October 2004
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.
Cases & Commentaries
A Room Without Orders
- Spotlight Case
- CME/CEU
- Web M&M
Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN; January 2016
Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.
Cases & Commentaries
Dual Therapy Debacle
- Web M&M
Steven R. Kayser, PharmD; September 2015
Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.
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.
Cases & Commentaries
No BP During NIBP
- Web M&M
Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc; September 2014
A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.
Cases & Commentaries
Discontinued Medications: Are They Really Discontinued?
- Web M&M
Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA; May 2014
An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.
Cases & Commentaries
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
- Spotlight Case
- Web M&M
Janice L. Kwan, MD; May 2014
An elderly woman with a history of dementia underwent surgical resection of new colon cancer, which relieved a bowel obstruction. She developed acute delirium postoperatively, and the team discovered they had neglected to capture her cholinesterase inhibitor patch (a medication for dementia) in the official medication reconciliation list.
Cases & Commentaries
Raise the Bar
- Web M&M
James Stotts, RN, MS, CNS, and Audrey Lyndon, PhD, RNC; May 2014
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Cases & Commentaries
CYP450 Drugs: Expect the Unexpected
- Web M&M
Charles John Gonzalez, MD; April 2014
Scheduled for a hip replacement, a man with AIDS presented with sciatica. The spine surgeon administered a corticosteroid injection to control his symptoms. Soon after the patient experienced sweats, abdominal pain, weight gain, elevated blood pressure, insomnia, and anxiety. He was diagnosed with Cushing syndrome due to an adverse interaction between the HIV medication and the corticosteroid.
Cases & Commentaries
Clostridium Difficile Relapse Secondary to Medication Access Issue
- Web M&M
Paul C. Walker, PharmD, and Jerod Nagel, PharmD; April 2014
Following a hospitalization for Clostridium Difficile–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.
Cases & Commentaries
After-Visit Confusion
- Web M&M
William Ventres, MD, MA; March 2014
A teenager presented to an urgent care clinic with new bumps and white spots near her tongue. Although she was diagnosed with herpetic gingivostomatitis, the after-visit summary incorrectly populated the diagnosis of "thrush" from the triage information, which was not updated with the correct diagnosis. The mistake on the printout caused confusion for the patient's mother and necessitated several follow-up communications to clear up.
Cases & Commentaries
Multifactorial Medication Mishap
- Spotlight Case
- Web M&M
Annie Yang, PharmD, BCPS; February 2014
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Cases & Commentaries
Check the Anesthesia Machine
- Web M&M
Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD; December 2013
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
Cases & Commentaries
New Oral Anticoagulants
- Spotlight Case
- Web M&M
Margaret C. Fang, MD, MPH; December 2013
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
Cases & Commentaries
Are You Mrs. A? An Issue of Identification Over Telephone
- Web M&M
Jason S. Adelman, MD, MS; October 2013
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
Cases & Commentaries
Finding Fault With the Default Alert
- Web M&M
Melissa Baysari, PhD; October 2013
An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.
Cases & Commentaries
Discharge Instructions in the PACU: Who Remembers?
- Web M&M
Kirsten Engel, MD; July-August 2013
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
Cases & Commentaries
Electrocardiogram Results: ***READ ME***
- Web M&M
Joseph S. Alpert, MD; November 2012
A woman with new onset chest pain was admitted to the hospital. Although the computer readout of her electrocardiogram stated "***ACUTE MI***" at the top, the nursing assistant who performed the test placed it in the patient's bedside chart without notifying a nurse or physician. The patient was, in fact, having a myocardial infarction, whose treatment was delayed.
Cases & Commentaries
Buprenorphine and the Medically Ill Patient
- Web M&M
Elinore F. McCance-Katz, MD, PhD; October 2012
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.