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- Culture of Safety 1
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- Error Reporting and Analysis 2
- Human Factors Engineering
- Quality Improvement Strategies 2
- Specialization of Care
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Search results for "Specialization of Care"
Journal Article > Study
Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist.
DuBose JJ, Inaba K, Shiflett A, et al. J Trauma. 2008;64:22-29.
Clinicians constantly encounter the challenge of how to ensure that appropriate patient safety measures are reliably carried out, especially in complex environments such as the intensive care unit (ICU). Preventable complications have been successfully reduced through the use of checklists, analogous to those used in aviation. This study used a "quality rounds checklist," which was completed by the ICU fellow, to ensure that trauma ICU patients received important patient safety interventions (including some recommendations of the 100,000 Lives campaign). Use of the tool resulted in significant reductions in ventilator-associated pneumonia and central line–associated bloodstream infections. A prior study implemented a similar tool to ensure multidisciplinary communication in the ICU.
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.
Journal Article > Review
Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward.
Gao H, McDonnell A, Harrison DA, et al. Intensive Care Med. 2007;33:667-79.
Rapid response teams are being widely implemented in hospitals worldwide. These teams are summoned to evaluate patients who meet specific clinical "triggers" (e.g., abnormal vital signs). This systematic review evaluated the ability of such triggers to accurately identify inpatients whose clinical condition is deteriorating. The false-negative rate of commonly used triggers was relatively high, meaning that a significant proportion of acutely unstable patients would not be identified by such criteria. This problem was noted in a prior negative study of rapid response teams. The authors recommend further research to determine the combination of triggers that most accurately identifies clinical instability.
Cases & Commentaries
- Web M&M
Susan C. Fagan, PharmD, BCPS, FCCP; April 2005
A patient with presumed stroke is given tPA before the results of her coagulation studies are known. Five minutes later, the lab reports that the INR was elevatedan absolute contraindication to thrombolytic therapy.
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.
Cases & Commentaries
- Spotlight Case
- Web M&M
Derek C. Angus, MD, MPH; Eric B. Milbrandt, MD, MPH; July 2004
Following a motor vehicle collision, a patient is mistakenly given drotrecogin alfa (activated) for organ failure not due to sepsis.