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- Communication Improvement 2
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Quality Improvement Strategies 2
- Teamwork 1
- Device-related Complications
- Diagnostic Errors 2
- Identification Errors 1
- Medical Complications 2
- Medication Safety 2
- MRI safety 1
- Nonsurgical Procedural Complications
- Surgical Complications
Search results for "Nonsurgical Procedural Complications"
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Journal Article > Study
Chang BH, Hsu YJ, Rosen MA, et al. Am J Med Qual. 2019 May 3; [Epub ahead of print].
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Journal Article > Commentary
Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.
This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.
Journal Article > Study
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.
Landro L. Wall Street Journal (Eastern edition). December 23, 2008;D2.
Emphasizing the importance of safe device use to prevent patient harm, this article reports on the top 10 technology hazards in hospitals according to ECRI Institute's annual list, which includes alarm hazards, retained fragments, misleading displays, and surgical fires.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.