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- Communication Improvement 1
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 2
- Logistical Approaches 1
Quality Improvement Strategies
- Audit and Feedback
- Teamwork 1
- Technologic Approaches 1
Search results for "Audit and Feedback"
Journal Article > Study
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
In this study, investigators identified possible medication errors using trigger tools, and a multidisciplinary team conducted real-time analyses to identify underlying system flaws contributing to the errors.
Cases & Commentaries
- Spotlight Case
- Web M&M
F. Daniel Duffy, MD; Christine K. Cassel, MD; October 2007
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.