Posted in AHRQ, Patient Safety Posted April 6, 2015
The Agency for Healthcare Research and Quality has released the April WebM&M, morbidity & mortality rounds on the web. Spotlighted case is “Dissecting the Presentation“, with additional cases: “Transition to Nowhere” and “Fire in the Hole! – An OR Fire“.
Surgical checklists are also addressed this month with an interview with Lucian Leape,MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, and an interview with David Urbach, MD, MSc, Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto.
Posted in Alerts, PSO Posted April 6, 2015
The Center for Patient Safety is issuing a Safety Alert based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- A pediatric patient receives a higher than standard dose of Propofol and requires resuscitation.
- A battery fails on an insulin IV pump and goes unnoticed.
- Approximately one in every five reported PSO medication events involves a high alert medication such as anticoagulants (warfarin, heparin, Lovenox), Propofol, insulin, hypoglycemic agents, opioids and so forth. Events relate to prescribing, dispensing, administering and monitoring errors.
Posted in Patient Safety, PSO Posted April 6, 2015
The Center for Patient Safety is issuing a Safety Watch based on industry data and recent findings from event data being submitted to the PSO. The following areas of concern have been reported to the PSO:
- Tube dislodgement during patient movement
- Patient aspiration
- Rapid Sequence Intubation
Posted in Uncategorized Posted March 18, 2015
The Center for Patient Safety (CPS) is pleased to share highlights of 2014 and expectations in 2015 in the latest annual report. We encourage you to take a look and see how you can join our journey to safer care in 2015!
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