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Search results for "Ambulatory Care"
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
Journal Article > Review
Taub N, Baker R, Khunti K, et al. Diabet Med. 2010;27:1322-1326.
This study found little research on safety improvement methods in the primary care of diabetes.
Journal Article > Study
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
Wrong-site surgeries are considered rare but devastating never events. However, a recent article suggested that wrong-site procedures may be more common than previously thought, since such errors can occur in procedures performed in areas other than the operating room. This study sought to evaluate the incidence of wrong-site surgery in pain management, using data from 10 facilities over a 2-year period. Although the overall incidence was low—only 13 cases were found with minimal associated patient harm—most cases were considered preventable, as clinicians failed to follow recommended preventive measures. A wrong-site surgery near miss is discussed in this AHRQ WebM&M commentary.
Journal Article > Commentary
Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.
Singh R, Singh A, Fox C, Seldan Taylor J, Rosenthal T, Singh G. Inform Prim Care. 2005;13:135-144.
The authors describe a systems engineering model of analysis and synthesis for understanding error in ambulatory care settings.