Narrow Results Clear All
- Communication Improvement 1
Error Reporting and Analysis
- Error Reporting
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Teamwork 1
Search results for "Error Reporting"
Cases & Commentaries
- Spotlight Case
- Web M&M
Thomas H. Gallagher, MD; May 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
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.