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- Communication Improvement
- Culture of Safety 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
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- Quality Improvement Strategies
- Specialization of Care 1
- Technologic Approaches 2
Search results for "Communication Improvement"
Cases & Commentaries
- Web M&M
Brian Clay, MD; January 2019
Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).
National Quality Forum. Washington, DC: National Quality Forum; 2010.
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intended to be universally applicable, "gold standard" interventions for reducing preventable harm, and have been widely endorsed and implemented. As in the 2009 update, the 34 specific practices are organized into seven content areas: creating a culture of safety, providing patient-centered care and disclosing errors, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. There are no major changes in the recommended practices since 2009, but the report contains specific recommendations on engaging patients and families in safety efforts.
Journal Article > Study
National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.
Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.
A 2006 Institute of Medicine report highlighted growing concerns about the state of emergency department (ED) care, particularly around overcrowding and its impact on safety. Medication errors are a known safety threat, and this study provides a cross-sectional perspective using reports from the MEDMARX database. Investigators found that physicians were responsible for 24% of errors while nurses were responsible for 54%. The administration phase was the most error-prone, and the most common error type was improper dose/quantity. Interestingly, computerized provider order entry was noted to cause 2.5% of the errors reported. The authors advocate for future interventions to improve medication safety in the ED. A past AHRQ WebM&M commentary discussed a near miss medication error in the ED that illustrates the many safety issues that contribute to this high-risk care setting.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.
Cases & Commentaries
- Web M&M
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.