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July 12, 2022
Radiologists Racked by Interruptions
Just as interruptions and distractions can be problematic for any clinician, they can also impact radiologists (see our Patient Safety Tip of the Week for July 1, 2014 “Interruptions and Radiologists” and our What's New in the Patient Safety World columns for November 2014 “More Radiologist Interruptions” and May 2018 “Cost of Interrupting a Radiologist”). If a radiologist gets interrupted while interpreting an imaging study, he/she may forget a point they were intending to make in a report. Or they may have to go back to square one and begin review of the imaging study as a brand new one. If interrupted while dictating a report, they may have to go back to the beginning to be sure they have included all the necessary information.
Unfortunately, “radiology rounds” have largely become a thing of the past. In the “old days” our team of attendings, residents and students would finish rounding on patients and then head down to the radiology suite. There we would meet with a radiologist and review the images of our patients that were all hanging on the radiology “boards?”. So, it was a time the radiologist set aside from interpreting images and dictating reports. Today, with images on PACS systems, clinicians are likely to view images on their patients remotely. When they have questions, they contact the radiologist by phone (or other method). This results in the radiologist having more frequent interruptions and incursions on their workflow.
In our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” we took a look at the impact of interruptions and distractions on the workflow of radiologists. A study (Yu 2014) found that during a typical 8PM to 8AM overnight shift there was an average of 72 telephone calls, with a median call duration 57 seconds, and the average time spent on the phone was 108 minutes. The median interval from the start of one telephone call to the start of the next ranged from 3 to 10 minutes, depending on the time of day. There was also a correlation between volume of phone calls and the volume of CT scans being done (volume of other imaging studies was not measured as part of this study). That study did not include any measure of image interpretation accuracy or disparities between interpretations by the on-call radiologist and any subsequent interpretations.
In our What's New in the Patient Safety World column for November 2014 “More Radiologist Interruptions” we noted another study found a relationship between telephone calls to radiology residents on-call and discrepancies on reports (Balint 2014). There was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report. The authors suggest that one additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error.
Recently, Shah and colleagues (Shah 2022) studied the workflow and impact of interruptions on pediatric radiologists at a large academic free-standing pediatric tertiary care facility with level 1 trauma. They found that total interruption time nearly equaled the total time interpreting studies for radiologists!
A business process improvement team was consulted to observe the activity of academic pediatric radiologists in the general, neuroradiology, and body reading rooms during daytime, evening, weekday, and weekend shifts. Activities were broken down into interpretation time (time spent reviewing and dictating studies), active interruptions (disruptions in interpretation initiated by the radiologist), and passive interruptions (disruptions in reading studies not initiated by the radiologist).
Three reading rooms were studied. The main reading room was responsible for interpreting the bulk of the radiographs and all inpatient ultrasound exams. It is situated close to the emergency department and is considered the “central hub” of the department. The neuroradiology reading room was responsible for all head, neck, and spine cross sectional imaging including CT and MRI scans. The body reading room was responsible for all cross-sectional non-neuro exams including musculoskeletal, cardiac, abdomen, and pelvic exams. Each reading area typically has 2 radiologists and up to 3 trainees, which may include medical students, residents, and fellows. Each reading area has its own workflow and resources. The main reading room had a dedicated reading room assistant who answers and triages incoming phone calls before notifying the radiologist.
Overall, radiologists spent 53% of their time interpreting studies, 18% on passive interruptions, and 29% on active interruptions, though the numbers varied by reading room type. Interruptions also varied by time of day with peaks during mid-morning and midafternoon times, corresponding with increased hospital-wide consultation of radiology. A majority of the interruptions were related to patient care.
Approximately 50% of non-interpretive time involved in-person conversations or consults (51% with colleagues, 17% with trainees, 16% with clinicians, and 14% with technologists). Other examples of non-interpretive activities included: calling a clinician, talking to a technologist, teaching a trainee, speaking with a colleague, signing paper orders, protocoling studies, responding to emails, administrative work, and technology issues. Phone calls represented 16% of non-interpretive time, of which 67% were incoming calls. Administrative work, including e-mail, comprised 13% of all non-interpretive time.
The longest time period recorded without an interruption was 20 minutes. Perhaps most importantly, 85% of the time an interruption came within 3 minutes of beginning an interpretation. 90% of interruptions lasted less than 3 minutes or less and 70% lasted 1 minute or less.
Interruptions clearly decreased efficiency and increased report interpretation times for all modalities studied. Interruptions not only cost the radiologist whatever time it took to address the interruption, but also cost additional total time to finalize the report dictation. Duplication of work occurred, as radiologists often needed to start again from the beginning when interpreting imaging studies.
There, of course, are “bad” interruptions and “good” interruptions. An interruption during which a radiologist conveys important information to a clinician is a “good” interruption. But, are there better ways to convey that information without interrupting the workflow of the radiologist? Shah and colleagues have some useful recommendations. They redesigned the central radiology reading room, combining the neuroradiology and body radiology reading rooms with sound barriers and strategic placement of a reading room assistant at the entrance to triage phone calls and direct visitors to the appropriate location. The reading room assistant hours were expanded to 24/7 and training was improved to assure consistency. Standardized phone call intake forms helped radiologists filter out non-urgent requests that could wait until an interpretative task was completed.
Asynchronous communication can help reduce radiologist interruptions and improve their workflow. Rather than having to respond to every individual phone call, some questions may be posed by text message or email and the corresponding responses made in between times when the radiologist is interpreting an imaging study or dictating a report. Fewer interruptions also mean the radiology reports can be posted on the PACS system or in the electronic medical record more promptly, further reducing the need for some interruptions. (Keep in mind the dangers of texting noted in our several columns listed below. However, most of those cautions apply to the issue of texting orders.)
Shah and colleagues implemented text-based communication through the EMR and phone-based application for more efficient communication with other departments and clinicians. A new PACS with worklist orchestrator and department-wide text-based communication is planned for the future.
They also addressed interruptions from radiology technologists. Imaging protocols were improved and standardized to minimize phone calls from technologists while assuring high quality image acquisition. Technologist training was also increased to allow for more independence and fewer instances of interrupting the radiologist.
And they modified trainee rotation schedules to assure that no more than one trainee would be with a radiologist at a time.
We suspect that an audit of interruptions for radiologists in most hospitals would reveal similar findings. The study by Shah and colleagues should give you some ideas to jump start a program of minimizing those interruptions and improving workflow and productivity of your radiologists.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
See our other Patient Safety Tip of the Week columns dealing with texting:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Yu J-P, Kansagra AP, Morgan J. The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications. JACR 2014; published online April 26, 2014
http://www.jacr.org/article/S1546-1440%2813%2900850-8/pdf
Balint BJ, Steenburg SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published online September 30, 2014
http://www.academicradiology.org/article/S1076-6332%2814%2900307-9/abstract
Shah SH, Atweh LA, Thompson CA, et al. Workflow interruptions and effect on study interpretation efficiency. Current Problems in Diagnostic Radiology 2022; Published online 27 June 2022
https://www.sciencedirect.com/science/article/abs/pii/S0363018822000871?via%3Dihub
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July 19, 2022
Sucked Out of the Plane at 17,000 Feet
Our regular readers know we like to use aviation analogies to make points about safety in healthcare (see list of prior columns below). We are giving a course on “Why Accidents Happen” and one of our examples is well worth telling here. The following comes from the book “Inviting Disaster” by James R. Chiles and 2 videos “Blow Out”, a short version and a long version.
On June 10, 1990 British Airways Flight 111 left Birmingham, England on a flight to Malaga, Spain with 87 passengers and crew aboard. As the aircraft climbed out, the captain and copilot unbuckled their chest straps but left their lap belts loosely fastened. Then, at 17,000 feet, the windscreen pulled loose and flew up and over the nose, snapped off a radio antenna and fell free. A force of 5500 pounds pulled the captain out of his seatbelt and launched him headfirst into the window frame. His legs and feet were lodged in the console but he was now mostly outside the plane in zero degree temperature and windspeed 396 miles per hour. Hypothermia was very likely to kill him even if he did not fall out completely.
The cockpit and cabin filled with fog (the decompression takes water vapor out of the air) and wind whistled through the cockpit at 350+ mph. The copilot could not hear anything else and could not communicate with air traffic control. The captain’s legs and feet, still lodged in the console, were actually causing the plane to increase speed. A downed cabin door also contributed to lack of access to controls. The copilot knew he must descend to lower altitude, so passengers and crew do not suffer from lack of oxygen. He must descend blindly over Heathrow airspace, one of the busiest in the world, thus risking a mid-air crash.
A flight steward enters the cockpit and grabs hold of the captain’s legs. Another steward enters and moves the fallen cabin door, freeing up the controls. The copilot descends to a safe level and makes contact with air traffic control (ATC). He asks for emergency landing at Gatwick Airport, which he is familiar with. ATC suggests Southampton airport instead. The copilot is concerned because he thinks he needs at least a 2200 meter runway (because of full fuel load that cannot be dumped) and Southampton has only 1800 meter runway. ATC still says to go to Southampton anyway and it deploys emergency vehicles there.
Flight stewards took turns holding the captain’s legs, while the copilot reduced speed and altitude. Crew was certain the captain was already dead and, at one point, had to decide whether to let the captain go. The decision to keep holding on to him was based as much on risk factors to the plane (fear his body would damage wings or jet engine) as well as the remote chance they could save him.
The copilot managed a safe emergency landing on the short runway at Southampton 18 minutes later. There the captain was whisked off in an ambulance. In the ambulance his eyes began to open. He’s still miraculously alive!!! He suffered frostbite, cuts and bruises, and several broken bones but survived. Five months later he returned to pilot again.
That was the drama. You can watch both a short version and a long version of these events online.
But the lessons came after the successful landing.
The investigation began immediately. There was no evidence of structural damage to the fuselage and no glass shards or fragments were found, so a bird strike or collision with other object was excluded. The investigator reviewed logs and saw that recent maintenance had been done. So the investigation moved back to Birmingham, England.
At 3:00 AM that morning the plane had rolled into the maintenance facility at Birmingham, England for a windscreen replacement that needed to be finished by 6:30 AM so the aircraft could get a wash before starting the day’s flight to Malaga, Spain. Windscreens must be strong enough to resist tons of force from cabin pressure when the airplane is at high altitudes. A hard-working maintenance manager decided to take on the awkward job of replacing the sixty-pound slab of layered glass and plastic himself. He began the job at 3:00 AM. He had replaced aircraft windscreens six times before, but he still read through that part of the maintenance manual quickly. Then he gathered his tools, positioned a scaffold, and climbed up to unscrew ninety bolts from the rim of the windscreen. He had a new windscreen ready and he had the pile of original bolts, eighty-four of which he knew to be of size 7D and six of them a little longer. But some of the bolt heads had globs of dried paint on them and others had been scarred from the removal process. He refused to take the easy course of using as many of the old bolts as possible, replacing only the damaged ones. He wanted to replace them all.
He went to the storeroom with a sample of the bolts he needed. The 7D bolt bin had only a few on hand, far less than he needed. The man in charge of the storeroom told him he should be using 8D bolts for a windscreen replacement, anyway. He disregarded that comment, figuring that since 7D bolts had worked before, they would work again. (The proper bolt actually was the 8D.)
There was a standby parts depot located two miles away, so he drove there. Most of the bins weren’t marked, none were supervised, and the lighting in this part of the building was bad. He kept digging until he found a bin of bolts that, when he held one up in the gloom alongside his old 7D, looked to be the same. In fact, the ones he found were neither 7D’s nor the proper 8D’s. The eighty-four unmarked bolts he loaded up and took back with him to the hangar were size 8C. They were one-fortieth of an inch narrower in diameter than the 7D’s he wanted. When he was finished, of all ninety bolts, only six long bolts of the correct size actually held the windscreen fast.
So, what were the contributing factors in this case that we also often see in healthcare incidents? The lead investigator in this incident said that there were “something like 13” contributing factors to this accident and that correction or avoidance of any one of them would have prevented the accident. Sound familiar? In healthcare incidents we typically see such a cascade of events and contributing factors, avoidance of any one of which would have prevented the adverse outcome.
Fatigue may well have played a role. The maintenance work took place in the middle of the night, beginning at 3:00 AM and not finishing until near the end of the maintenance manager’s shift. Time pressures clearly played a role. This work had to be done so the flight could get washed at 6:30 AM prior to its early departure time. So, all the work had to be compressed into the period between 3:00 AM and 6:00 AM. In the airline industry (and most industries), “time is money”.
Work overload likely contributed as well. There were so many ongoing maintenance jobs that the manager had to do this job on his own. In addition, there were likely distractions, since the manager was in charge of all work being done and was concerned how all the other jobs were going, even while doing his own project.
Workarounds were a major contributor. People often take pride in their workarounds and may be considered “resourceful” Some workarounds are indeed “resourceful” and useful, but most are not and can be dangerous. In this case, the workaround was that the manager did not look at the parts catalog. He told the investigators, apparently with a sense of pride, that finding the correct bolts is “easier to do visually”. In fact, bypassing the parts catalog apparently had become the norm in this maintenance facility. We refer to that as “normalization of deviance”.
Assumptions played a big role. The manager matched up bolts to the ones he had removed. The old ones had been in place for 4 years, apparently without incident. He assumed that, if the old ones worked, the new ones will work.
And 2 of the common cognitive biases we so often see in healthcare incidents came into play here: confirmation bias and ignoring disconfirming evidence. The bolts looked like they were the same size as the ones he had removed. “I got 7D bolts out, I put 7D bolts back in”. There were at least 2 bits of disconfirming evidence. He ignored stockroom worker’s warning that those were not the correct bolts and he also ignored the fact that the bolts went in without the usual resistance you’d expect when putting them in.
Overconfidence (or hubris) also played a role. When asked why he ignored the storeroom clerk’s statement that those were the wrong bolts, the manager said “Well, I’m an engineer…”.
There were also environmental factors. The hangar was full and the plane was pushed up against a wall, making it difficult for the manager to work on the windscreen. The lighting in the auxiliary parts storeroom was poor, making identification of the bolts difficult.
And there was also a critical design flaw. The bolts on this aircraft windscreen went in from the outside. On newer models, the bolts go on the inside. If the bolts loosened at high altitude, the higher cabin pressure inside the plane would push the windscreen against the fuselage rather than having the windscreen blow out as it would on the old design.
And there was probably a latent factor: the old bolts were actually the wrong size!!! It’s incredible this accident had not occurred earlier. Perhaps those 6 long bolts had been originally located just strategically enough to prevent a blowout?
When we look at an incident, there is typically a “sharp” end. The root causes and other contributing factors at the “blunt” end add up and leave a human with “the smoking gun”. The lead investigator in this incident said “This investigation uncovered pressures in the hangar that caused an otherwise proficient engineer to make potentially lethal mistakes while being certain he was doing the right thing”.
Lastly, this incident was technically a “near miss” since the ultimate outcome for the pilot and the 87 passengers and crew was not physically detrimental. As in many healthcare incidents that are “near misses”, a little bit of luck is important. On the bad luck side, the pilot happened to be sitting on the side of the defective windscreen and had loosened his shoulder harness. On the good luck side, all were lucky the plane did not hit any other planes as they descended blindly through crowded airspace and that the runway was just long enough for a fully fueled plane to be able to stop. And the hypothermia the captain undoubtedly experienced as he lay outside the aircraft may well have protected his brain from the lack of oxygen he also undoubtedly experienced.
We know this is not a healthcare incident. But we hope you can all see the common root causes, latent factors, cognitive biases, and other contributing factors seen in this case are often present in our serious healthcare incidents. If you have time, the long version is quite dramatic and worth watching. It’s just over 51 minutes but you’ll be impressed by it.
This case is also a reminder that accidents often follow maintenance activities. Many high profile industrial disasters (Three Mile Island, Chernobyl, Bhopal, Piper Alpha) and many airline disasters occurred during maintenance procedures. Our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents” discussed the book “Managing Maintenance Error” by James Reason and Alan Hobbs. Maintenance may be a factor in some healthcare incidents as well. Our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” described a near-miss in which tape placed over an oxygen blender alarm on a ventilator during maintenance resulted in lack of a warning when the ventilator became disconnected from it oxygen source while in use on a patient.
See some of our previous columns that use aviation analogies for healthcare:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
August 7, 2007 “Role of Maintenance in Incidents”
August 28, 2007 “Lessons Learned from Transportation Accidents”
October 2, 2007 “Taking Off From the Wrong Runway”
May 19, 2009 “Learning from Tragedies”
May 26, 2009 “Learning from Tragedies. Part II”
January 2010 “Crew Resource Management Training Produces Sustained Results”
May 18, 2010 “Real Time Random Safety Audits”
April 5, 2011 “More Aviation Principles”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
May 8, 2012 “Importance of Non-Technical Skills in Healthcare”
March 5, 2013 “Underutilized Safety Tools: The Observational Audit”
April 16, 2013 “Distracted While Texting”
May 2013 “BBC Horizon 2013: How to Avoid Mistakes in Surgery”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 17, 2013 “The Second Victim”
January 7, 2014 “Lessons from the Asiana Flight 214 Crash”
January 5, 2016 “Lessons from AirAsia Flight QZ8501 Crash”
October 23, 2018 “Lessons From Yet Another Aviation Incident”
References:
Chiles JR.. Inviting Disaster. HarperCollins. Kindle Edition. 2008
Blowout (short version). British Airways Flight 5390; October 22, 2016
https://www.youtube.com/watch?v=pOcm6E10anI
Blow Out (full episode). The Captain That Got Stuck Outside Of The Plane! Mayday: Air Disaster; September 10, 2021
https://www.youtube.com/watch?v=7xfaDr0nhoQ
Reason J, Hobbs A. Managing Maintenance Error. Aldershot, England: Ashgate Publishing Limited, 2003
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July 26, 2022
More Risks in the Radiology Suite
You’ve seen our multiple columns describing the radiology suite as being high-risk for patient safety events. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” and the other columns listed below we’ve discussed the multitude of safety issues seen in radiology suites that have little to do with radiology per se. That’s because sick patients with multiple medical problems and vulnerabilities are being taken to the radiology suite and staying there, sometimes for prolonged periods. The events include things like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others.
But sometimes factors related to the imaging procedure may also contribute to patient safety events. Sanchez et al. (Sanchez 2022) recently discussed cases of 2 patients given IV sedation to facilitate MRI scans. In one, a 43-year-old woman with acute neurological symptoms and signs was given lorazepam 2 mg intravenously (IV) as premedication to reduce agitation after a first attempt at doing the MRI was unsuccessful. The MRI was again unsuccessful, despite anxiolysis. After returning to the medical unit, flumazenil 0.2 mg was given due to somnolence, with subsequent improvement in mental status.
In the second case, a 71-year-old man with a possible epidural abscess following a bout of sepsis was sent for an MRI scan. He was unable to tolerate the scan due to back pain, so hydromorphone 0.5 mg IV was administered. Because of continued restlessness, additional doses of lorazepam 1 mg IV and hydromorphone 0.4 mg IV were ordered. After the patient received a 3rd dose of lorazepam 1mg IV, he became obtunded, hypotensive, and developed respiratory depression with oxygen saturation around 60%. The rapid response team was called, and naloxone and flumazenil were administered. The patient was placed on bilevel positive airway pressure (BiPAP) and given a fluid bolus before being transported to the intensive care unit (ICU), where he was emergently intubated. The patient remained intubated for several days due to severe acute respiratory distress syndrome (ARDS), which was attributed to aspiration while in the MRI machine.
Sanchez et al. provide a nice discussion of the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required, and when monitoring is limited or inadequate (e.g., inside an MRI machine). They highlight the need for risk assessment prior to administering such drugs and consideration of patient-specific risk factors for respiratory depression. They stress such risk factors for oversedation as obesity, hepatic, renal, and lung disease; substance use disorder, and obstructive sleep apnea. They recommend looking for higher American Society of Anesthesia (ASA) physical status classification and checking a STOP-BANG score to help identify patients who might have unrecognized obstructive sleep apnea. In addition, they note that lower BMI values are associated with higher plasma concentrations of fentanyl or midazolam, two commonly used medications for diagnostic imaging sedation. They also suggest assessing the patient for potential aspiration risk and considering NPO (nothing by mouth) orders prior to diagnostic imaging procedures with sedation.
They caution against “dose-stacking” of medications (administering medications multiple times and/or from various routes before each dose reaches its peak therapeutic effect).
Monitoring is very important. Because of variability and risk for oversedation, patients must be assessed before and after each dose or medication administration. They note that consistent sedation assessments are important throughout the duration of action of the medication(s) administered. They emphasize “Continuous electronic monitoring is indicated for moderate levels of sedation or higher and should be considered for high-risk patients receiving opioids and/or benzodiazepines.”
They also stress an important point that is often overlooked – sedation might be avoided all together in many patients. They discuss non-pharmacologic techniques that can be used to minimize anxiety, agitation, and claustrophobia prior to such imaging studies. These include positioning issues, use of movie goggles, mirrors, 2-way communications, call buttons, and even fragrance administration.
Nice, practical discussion of a problem we continue to see all too often in patients undergoing imaging studies.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
References:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. AHRQ PSNet Web M&M July 8, 2022
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
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July 26, 2022
More Risks in the Radiology Suite
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Sucked Out of the Plane at 17,000 Feet
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Radiologists Racked by Interruptions
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February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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