Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Logistical Approaches 2
- Quality Improvement Strategies 4
- Technologic Approaches 3
- Device-related Complications 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Errors/Preventable Adverse Drug Events 3
- MRI safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Hospital Medicine"
- Hospital Medicine
ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.
Neuromuscular blockers can result in serious harm if administered incorrectly. This newsletter article reports the types of errors associated with the use of these high-alert medications, such as look-alike and sound-alike problems that lead to the wrong drug being administered. Recommended strategies to reduce risks include use of standardized prescribing and smart pump technologies.
Journal Article > Study
Prewitt J, Schneider S, Horvath M, Hammond J, Jackson J, Ginsberg B. J Patient Saf. 2013;9:103-109.
Patient-controlled analgesia (PCA) devices were designed to provide safe administration of opiate analgesics, but PCA-related medication errors do still occur. Due to the dangers associated with opiate use, these errors can be fatal. This study provides a retrospective review of PCA adverse drug events at Duke University Hospital before and after implementation of clinical decision support with computerized provider order entry and PCA smart pump technology. The rate of adverse drug events per 1000 patient PCA days decreased from 5.3 (pre-intervention) to 4.2 (post-intervention). This modest but important improvement supports medical centers' investment in these strategies. A prior AHRQ WebM&M commentary discusses a case of a fatal PCA overdose.
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Journal Article > Study
Kolbe M, Weiss M, Grote G, et al. BMJ Qual Saf. 2013;22:541-553.
Teamwork training studies have been criticized for not rigorously evaluating participants' skill acquisition and behavior changes. This study reports on the development and validation of a theory-based method for debriefing after teamwork training.
Journal Article > Review
Woodall N, Frerk C, Cook TM. Anaesthesia. 2011;66(suppl 2):27-33.
This commentary summarizes a report on airway management safety in the United Kingdom and suggests tactics to generate improvements.
Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.
Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that no regulatory efforts have been implemented to improve MRI safety in the 10 years following the incident.
Journal Article > Commentary
An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.
Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.
This commentary describes how an anesthesiology department engaged residents in quality and patient safety initiatives and discusses the resulting impact on medication reconciliation, process improvement, laboratory ordering, and patient safety awareness.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
Cases & Commentaries
- Web M&M
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.