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Search results for "Indwelling Tubes and Catheters"
Cases & Commentaries
- Web M&M
Angela C. Joseph, RN, MSN, CURN; November 2006
Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics.
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
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.