Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Technologic Approaches 4
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 1
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Search results for "Information Professionals"
Special or Theme Issue
Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.
This special issue includes articles discussing safety in anesthesiology practice as well as quality improvement innovations.
Journal Article > Study
Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.
Grunebaum A, Chervenak F, Skupski D. Am J Obstet Gynecol. 2011;204:97-105.
Implementing a comprehensive safety program, which included teamwork training, additional staffing and reduction of work hours, electronic medical records, and a dedicated patient safety nurse, was associated with a sharp reduction in malpractice lawsuits and sentinel events at an academic hospital.
Journal Article > Commentary
Manor PJ. Nurs Manage. 2010;41:18-20.
This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE) implementation projects to achieve CPOE success.
Cases & Commentaries
- Web M&M
Clarence H. Braddock III, MD, MPH; November 2008
A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.
Journal Article > Study
Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.
This study reports the initial findings from a voluntary, Web-based patient safety incident reporting system for intensive care units (ICUs). The system, developed through funding by the Agency for Healthcare Research and Quality (AHRQ), collected data on incidents that could have resulted in patient harm. During the study, more than 2000 reports were filed from 23 participating ICUs. A substantial minority (42%) of incidents led to patient harm, and most had multiple contributing factors, such as deficiencies in training or teamwork. The authors note that the science of incident reporting systems is still in its infancy and recommend that future research should study how to use incident reporting data to improve patient safety.