Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 4
- Education and Training 5
- Error Reporting and Analysis 5
- Human Factors Engineering 10
- Legal and Policy Approaches 6
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 4
- Device-related Complications 5
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 1
- Medical Complications 3
- Medication Errors/Preventable Adverse Drug Events 11
- MRI safety 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 16
- Nursing 6
- Pharmacy 2
- Health Care Executives and Administrators 20
Health Care Providers
- Nurses 6
- Physicians 10
- Non-Health Care Professionals 11
- Patients 12
Search results for "Anesthesiology"
- Newspaper/Magazine Article
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
ISMP Medication Safety Alert! Acute Care Edition. June 16, 2016;21:1-6.
Neuromuscular blockers can result in serious harm if administered incorrectly. This newsletter article reports the types of errors associated with the use of these high-alert medications, such as look-alike and sound-alike problems that lead to the wrong drug being administered. Recommended strategies to reduce risks include use of standardized prescribing and smart pump technologies.
Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.
ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3.
ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.
Describing a tubing misconnection error, this newsletter identifies contributing factors and recommends precautions to prevent similar incidents.
Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.
Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that no regulatory efforts have been implemented to improve MRI safety in the 10 years following the incident.
Challenges ahead in technology training: a report on the training initiative of the Committee on Technology.
Olympio MA, Reinke B, Abramovich A. APSF Newsletter. Fall 2006;21:43-48.
The authors describe the complexity of keeping current on new anesthesia equipment and propose an in-depth process for physician and technician training to ensure safe use in the operating room.
Oakeshott I. The Sunday Times. June 18, 2006.
This article reports on incidents of wrong drug and wrong route administration of epidurals in the United Kingdom's National Health Service.
ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.
This article outlines systems failures that can contribute to the inadvertent misadministration of IV medications and provides several recommendations to support safe practices.
Hallinan JT. Post-Gazette.com. June 21, 2005.
This article summarizes the history of patient safety improvement in anesthesia and its impact on malpractice claims and costs within that specialty.
Foreman J. Boston Globe. February 8, 2005.
A patient shares her story of awakening during surgery and describes the psychological impact of the experience.
ISMP Medication Safety Alert! Acute Care Edition. December 16, 2004;9:1-2.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Janik LS, Vender JS Grissinger M, Litman RS. APSF Newsletter. February 2019;33:72-75.
This pair of commentaries reviews the use of color-coded medications as an anesthesia safety strategy. The first article argues for implementing standard color sets to delineate drug class and use to improve medication safety. The dissenting article suggests that color-coded medications may decrease the chance of clinicians reading syringe labels carefully due to overreliance on color representation as a shortcut for reading the label.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
ISMP Medication Safety Alert! Acute Care Edition. November 5, 2015;20:1-5.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
Saltzman W. ABC/WPVI. February 5, 2013.
ISMP Medication Safety Alert! Acute Care Edition. July 29, 2010;15:1-4.
This article discusses medication shortages and how they exacerbate medication error and treatment delay. The piece includes a link to a brief survey on this topic.
Chen PW. New York Times. January 28, 2010.
This newspaper column explains how simulation training is being integrated into medical education to help clinical teams improve their skills and ensure patient safety.
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.