Debora Simmons

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A 24-year-old woman was 35 weeks pregnant when she was hospitalized for vomiting and dehydration. A bag of ready-to-hang enteral feeding was brought to the floor, and the nurse, assuming it was total parenteral nutrition, which the woman had received on previous admissions, pulled regular intravenous tubing from floor stock, spiked the bag, and started the(More)
This report describes the development and implementation of The University of Texas Close Call Reporting System, an anonymous tool used to collect information about potential errors that do not reach the patient. The system was originally developed through experimentation, using a fund of knowledge collected in the aviation industry. A multidisciplinary(More)
ii Acknowledgments The authors gratefully acknowledge the intellectual contributions from the following reviewers: iii DISCLAIMER Certain commercial entities, equipment, or material may be identified in this document in order to describe a concept adequately. Such identification is not intended to imply recommendation or endorsement by the National(More)
iii In addition, the authors appreciate the access to the data collected under NIST contract number SB134110CN0107 (UL-Wiklund) and the many instructive contributions from a broad spectrum of stakeholders on the draft document during an invited stakeholder meeting held at the National Institute of Standards and Technology on September 28, 2015, as well as(More)
In addition, the authors appreciate the access to the data collected under NIST contract number SB134110CN0107 (UL-Wiklund) and the many instructive contributions from a broad spectrum of stakeholders on the draft document during an invited stakeholder meeting held at the National Institute of Standards and Technology on September 28, 2015, as well as peer(More)