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Cases & Commentaries
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Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Journal Article > Study
Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.