Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 3
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 1
- Medication Safety
- Psychological and Social Complications 1
- Surgical Complications 5
Search results for "Medication Safety"
Cases & Commentaries
- Web M&M
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD; June 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Special or Theme Issue
Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.
This special issue includes articles discussing safety in anesthesiology practice as well as quality improvement innovations.
Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.
To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a better understanding of human error and to adopt lasting safety principles.
Cases & Commentaries
- Web M&M
Pascale Carayon, PhD; May 2007
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
Journal Article > Study
Garnerin P, Huchet-Belouard A, Diby M, Clergue F. Acta Anaesthesiol Scand. 2006;50:1114-1119.
The authors describe the systematic analysis of an incident involving inappropriate use of a medical device and discuss how their process for understanding and resolving the problem supported the safety culture in their organization.
Perspectives on Safety > Interview
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.
This article discusses the application of several Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goals in ambulatory surgery centers (ASCs) and interviews one practitioner about implementing patient safety interventions in his ASC.