Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "General Hospitals"

1 - 20 of 146 results
Download Selected Citations

Show: 20 | 50 | 100

Cases & Commentaries

Chest Tube Complications

  • Web M&M

Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Journal Article > Commentary

Who is responsible for the safe introduction of new surgical technology? An important legal precedent from the da Vinci Surgical System Trials.

Pradarelli JC, Thornton JP, Dimick JB. JAMA Surg. 2017 May 3; [Epub ahead of print].

This commentary explores the responsibility of organizations, device manufacturers, and clinicians for ensuring surgeon technical expertise in the use of robotic surgical equipment. The authors describe how hospitals and individual practitioners can enhance their capabilities with new technology to ensure safe patient care.

Cases & Commentaries

Communication Error in a Closed ICU

  • Web M&M

Barbara Haas, MD, PhD, and Lesley Gotlib Conn, PhD; May 2017

Admitted to the ICU with septic shock, a man with a transplanted kidney developed hypotension and required new central venous access. Since providers anticipated using the patient's left internal jugular vein catheter for re-starting hemodialysis (making it unsuitable to use for resuscitation), the ICU team placed the central line in the right femoral vein. However, they failed to recognize that his transplanted kidney was on the right side, which meant that femoral catheter placement on that side was contraindicated.

Journal Article > Study

Two-state collaborative study of a multifaceted intervention to decrease ventilator-associated events.

Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.

Patients requiring intensive care are particularly vulnerable to preventable adverse events, including health care–associated infections. This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients requiring mechanical ventilation in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the Comprehensive Unit-based Safety Program, focusing on implementing evidence-based safety processes by explicitly addressing barriers to improvement and engaging in regular data audit and feedback. Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including ventilator-associated pneumonia) over the study period. Although the study is limited by lack of a concurrent control group, the results indicate the power of collaborative efforts to drive large-scale improvement.

Journal Article > Commentary

Management of a patient with a latex allergy.

Minami CA, Barnard C, Bilimoria KY. JAMA. 2017;317:309-310.

This case analysis discusses the use of a latex catheter in a patient with a known latex allergy and presents how root cause analysis identified factors that contributed to the error. Recommended corrective actions included educating staff about latex allergies and using a checklist to address communication, documentation, and process weaknesses.

Cases & Commentaries

A Potent Medication Administered in a Not So Viable Route

  • Web M&M

Osama Loubani, MD; January 2017

A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.

Newspaper/Magazine Article

Accidental IV infusion of heparinized irrigation in the OR.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.

Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.

Journal Article > Study

Incidence of speech recognition errors in the emergency department.

Goss FR, Zhou L, Weiner SG. Int J Med Inform. 2016;93:70-73.

The adoption of new technology in health care often produces unintended consequences, which can be mitigated by applying human factors engineering principles to user interface design. Due to efficiency gains, the use of speech recognition technology among physicians has grown in recent years. Investigators analyzed notes dictated by emergency medicine physicians and found that 71% of the notes contained errors. Given that 15% of the errors were considered critical, the authors suggest speech recognition technology may create miscommunication that could adversely affect patient care.

Cases & Commentaries

Robotic Surgery: Risks vs. Rewards

  • Spotlight Case
  • CME/CEU
  • Web M&M

Tara Kirkpatrick, MD, and Chad LaGrange, MD; February 2016

Despite mechanical problems with the robotic arms during a robotic-assisted prostatectomy, the surgeon continued using the technology and completed the operation. Following the procedure, the patient developed serious bleeding requiring multiple blood transfusions, several additional surgeries, and a prolonged hospital stay.

Newspaper/Magazine Article

Raising an alarm, doctors fight to yank hospital ICUs into the modern era.

McFarling UL. STAT. September 7, 2016.

Intensive care units (ICUs) are complex environments that harbor various challenges to safe care delivery. Reporting on alarm fatigue and insufficient interoperability between devices in ICUs, this news article describes solutions to address data overload and highlights the efforts of several hospitals working toward developing ICUs that are more respectful of patients and the clinical teams caring for them.

Cases & Commentaries

Departure From Central Line Ritual

  • Web M&M

Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015

A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.

Journal Article > Study

Influence of the Comprehensive Unit-based Safety Program in ICUs: evidence from the Keystone ICU project.

Hsu YJ, Marsteller JA. Am J Med Qual. 2016;31:349-357.

To determine the impact of the Comprehensive Unit-Based Safety Program (CUSP) on patient safety, this study compared intensive care units participating in the program with units not participating. Although safety culture improved in units with CUSP implementation, the intervention did not reduce incidence of central line–associated bloodstream infections. These findings demonstrate that teamwork training approaches, while helpful, may not be sufficient to augment patient outcomes. Further study characterizing sites that improved versus those that did not may elucidate facilitators and barriers to achieving patient safety goals.

Journal Article > Study

Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients.

  • Classic

Drew BJ, Harris P, Zègre-Hemsey JK, et al. PLoS One. 2014;9:e110274.

Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.

Journal Article > Study

Cost-effectiveness of a quality improvement programme to reduce central line–associated bloodstream infections in intensive care units in the USA.

Herzer KR, Niessen L, Constenla DO, Ward WJ Jr, Pronovost PJ. BMJ Open. 2014;4:e006065.

This study analyzed the cost-effectiveness of the Keystone ICU project, a highly successful program for preventing central line–associated bloodstream infections. The authors found that the intervention achieved improved safety at no additional cost to hospitals.

Grant

Patient Safety in the Context of Perinatal, Neonatal, and Pediatric Care.

Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. August 6, 2014. PA-14-311; PA-14-312; PA-14-313.

This three-component funding program will support collaborative research, program distribution, and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units.

Journal Article > Study

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.

Manrique-Rodríguez S, Sánchez-Galindo AC, López-Herce J, et al. Int J Technol Assess Health Care. 2014;30:210-217.

This study applied failure mode and effect analysis (FMEA) to identify possible risks associated with smart infusion pumps. The investigators used the results to develop training, enhance medication information, and reduce alert fatigue by distinguishing dose programming errors from pump misuse alarms. These findings demonstrate the effectiveness of utilizing a systems approach to address safety issues.

Journal Article > Study

Training induces cognitive bias: the case of a simulation-based emergency airway curriculum.

Park CS, Stojiljkovic L, Milicic B, Lin BF, Dror IE. Simul Healthc. 2014;9:85-93.

This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.

Cases & Commentaries

An Easily Forgotten Tube

  • Web M&M

Karen Ousey, PhD, RGN; February 2014

A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.

Journal Article > Study

Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.

Sacks GD, Diggs BS, Hadjizacharia P, Green D, Salim A, Malinoski DJ. Am J Surg. 2014;207:817-823.

The introduction of the Institute for Healthcare Improvement central line bundle into a surgical intensive care unit dramatically reduced the incidence of central line–associated bloodstream infections, preventing an estimated 2.5 deaths per year in this single unit.

Journal Article > Study

Successful implementation of a unit-based quality nurse to reduce central line–associated bloodstream infections.

Thom KA, Li S, Custer M, et al. Am J Infect Control. 2014;42:139-143.

Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and mortality. Efforts to combat these complications include implementation of checklists and—perhaps more importantly—the enhancement of safety culture. Despite the widespread success of these interventions, some institutions continue to experience CLABSI rates that are above national benchmarks. This study describes the introduction of a unit-based quality nurse dedicated to preventing CLABSIs within a surgical intensive care unit (ICU) at an academic medical center. The quality nurse helped to educate staff about health care–associated infections and prevention strategies. The nurse also provided immediate, direct feedback to staff regarding their compliance with best practices. The average CLABSI rate decreased significantly, even after adjusting for multiple factors including reduction in CLABSI rates in other adult ICUs. A unit-based quality nurse may prove to be a powerful adjunct to the current available tools for reducing these costly infections.

Back to Top