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- Education and Training
- Error Reporting and Analysis 1
- Human Factors Engineering 5
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
Search results for "Education and Training"
Journal Article > Study
Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.
Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. January 26, 2010;(44):1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will being distributed by a new initiative.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Journal Article > Review
Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.
This review explores how placing inappropriate trust in the reliability of complex equipment in the ICU may pose patient safety risks.
Journal Article > Study
Waldrop WB, Murray DJ, Boulet JR, Kras JF. Anesth Analg. 2009;109:426-433.
Kaji AH, Cone DC, eds. Acad Emerg Med. 2008;15:971-1222.
This special issue highlights an AHRQ-funded symposium on the role of simulation in medical education and covers topics such as teamwork training and skill improvement.
Cases & Commentaries
- Web M&M
Verna C. Gibbs, MD; Lucian L. Leape, MD ; February 2003
A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.