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Stephanie Rogers, MD, and Derek Ward, MD; April 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2016.
Learning organizations are capable of addressing problems through information sharing and learning from past experience to facilitate improvement and innovation. Large system failure occurs when such interventions are not disseminated and implemented. This report discusses the need to ensure that lessons learned in military trauma care are acted on and sustained and recommends that this information be translated for the civilian health system as a way to reduce preventable patient harm in trauma care.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2005. AHRQ Publication No. 05-P003-3.
This program brief summarizes patient safety research projects funded by the Agency for Healthcare Research and Quality (AHRQ) since 2001.