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Journal Article > Study
Facilitation of surgical innovation: is it possible to speed the introduction of new technology while simultaneously improving patient safety?
Marcus RK, Lillemoe HA, Caudle AS, et al. Ann Surg. 2019 Mar 26; [Epub ahead of print].
Although the introduction of new technology in health care is crucial for advancing patient care, unintended consequences are a well-recognized safety challenge. In the field of surgery, innovation ranges from small improvements to drastic change, but there is no clearly established model for evaluating proposed innovations. This study examined the impact of a team of surgical quality officers and perioperative nurses tasked with reviewing proposed surgical innovations, including novel devices and procedures at a single cancer center. Investigators found that compared to the prior processes in place, this team evaluated new products more quickly, decreased the time between product proposal and the intraoperative trial if necessary, and reduced the rate of device-related complications from 10% to 0%. A past PSNet perspective discussed the evolution of patient safety in the field of surgery.
Journal Article > Review
Jones TS, Black IH, Robinson TN, Jones EL. Anesthesiology. 2019;130:492-501.
Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Journal Article > Study
Estock JL, Pham IT, Curinga HK, et al. Jt Comm J Qual Patient Saf. 2018;44:683-694.
Hypoglycemia can lead to catastrophic adverse events if not acted upon quickly. Researchers tested an easier-to-read display for a glucometer commonly used in hospitals. This human factors engineering approach enabled nurses in simulations to more accurately interpret and respond to low blood sugar readings.
Trossman S. Am Nurse. Sept/Oct 2013;45:1,6-7.
This article reports on the widespread issue of alarm fatigue and describes strategies to manage alarms and improve safety.
Cases & Commentaries
- Spotlight Case
- Web M&M
David M. Gaba, MD ; October 2004
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.