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Approach to Improving Safety
Safety Target
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Interruptions and distractions
- Medication Safety 1
- Surgical Complications 1
Search results for "Interruptions and distractions"
- Interruptions and distractions
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Journal Article > Study
Nursing home error and level of staff credentials.
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
This study investigated whether type of credentials affected rates of medication errors and found no significant difference. However, the authors noted that nurses were interrupted more often during medication administration.
Cases & Commentaries
All in the History
- Spotlight Case
- Web M&M
Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Cases & Commentaries
Fumbled Handoff
- Web M&M
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
