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- Culture of Safety 1
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
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- Quality Improvement Strategies
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems
- Identification Errors 2
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Search results for "Medicine"
Journal Article > Review
Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.
This review addresses surgical specimen analysis errors and highlights tactics to improve the reliability of the process.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Journal Article > Study
Registration-associated patient misidentification in an academic medical center: causes and corrections.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
In response to multiple incidents of registration-associated patient misidentification (eg, assigning a new patient an existing patient's medical record number), an interdisciplinary team used plan-do-study-act methodology to investigate the root cause of such errors and formulate solutions. Several system problems were identified, ranging from inadequate training of registrars to the lack of a true master list of patients' medical record numbers. The authors describe the iterative process used to identify and address sources of error at several points within the patient registration process.
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.