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Search results for "Device-related Complications"
- Device-related Complications
- Outpatient Surgery
Special or Theme Issue
Azar FM, ed. Orthop Clin North Am. 2018;49:A1-A8,389-552.
Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. April 8, 2013;(50):1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Cases & Commentaries
- Web M&M
Jose L. Baez-Escudero, MD; Glenn N. Levine, MD; September 2007
A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died.
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.