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Search results for "Policies and Operations"
- Noncognitive Errors ("Slips & Lapses")
- Policies and Operations
DeMarco P. Globe Magazine. November 3, 2018.
This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.
Journal Article > Review
Cornes M, Ibarz M, Ivanov H, Grankvist K. Diagnosis (Berl). 2019;6:33-38.
Common blood sample errors, such as mislabeling or patient misidentification, can contribute to diagnostic delays. This review highlights the importance of using open-ended questions to gather information from patients and suggests that specimens be labeled with the patient present to ensure accurate verification. A WebM&M commentary explored problems associated with mislabeled blood samples.
Journal Article > Commentary
Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.
This commentary describes an initiative to address discrepancies in surgical count policies and improve standards for preventing retained surgical objects.