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BACKGROUND Studies have established that physiologic instability and services mismatching precede adverse events in hospitalized patients. In response to these considerations, the concept of a Rapid Response System (RRS) has emerged. The responding team is commonly known as a medical emergency team (MET), rapid response team (RRT), or critical care outreach(More)
We are all "hard wired" to have limited ability to quickly and accurately communicate and work with each other. These limitations are especially acute in our urgent, stressful, and interruption-filled world. New views on these limitations include phenomena-like situational awareness and inattentional blindness. Development and testing of communication tools(More)
BACKGROUND The need to provide efficient, effective, and safe patient care is of paramount importance. However, most physicians receive little or no formal training to prepare them to address patient safety challenges within their clinical practice. METHODS We describe a comprehensive Patient Safety Learning Program (PSLP) for internal medicine and(More)
OBJECTIVES In an effort to improve patient safety attitudes and skills among third-year medical students, two patient safety training sessions were added to their curriculum, complementing a previously implemented second-year curriculum on quality improvement, patient safety and teamwork. METHODS Safety attitudes and skills were assessed before and after(More)
A case study is presented, based on the experience of the US Veterans Affairs health system, which shows the benefits of healthcare personnel understanding human factors engineering (HFE) and how it relates to patient safety. After HFE training, personnel are better able to use a systems-oriented approach during adverse event analysis. Without some(More)
OBJECTIVE To describe the washout effect after stopping a prevention checklist for ventilator-associated pneumonia (VAP). METHODS VAP rates were prospectively monitored for special cause variation over 42 months in a paediatric intensive care unit. A VAP prevention bundle was implemented, consisting of head of bed elevation, oral care, suctioning(More)
Geographic disorientation in aviation operations results from the failure of an aircrew to recognize and/or maintain the desired position relative to the external ground and airspace environment. Becoming lost during flight, intruding inadvertently into unauthorized airspace, selecting a wrong airway, landing on the wrong runway, and approaching the wrong(More)
Knowledge of venous, capillary, and arterial blood flow in microgravity is required to modify hemostatic techniques for control of bleeding in traumatic injuries or surgical procedures in space. To simulate human arterial, venous, and capillary bleeding, fresh whole bovine blood was injected by two operators at calculated flow rates (3.5, 7, and 14 mL for(More)
INTRODUCTION Emergency department procedural sedation (EDPS) is becoming widespread. Simulation may enhance patient safety through evidence-based training, effective assessment, and research of EDPS operators in pertinent knowledge, skills, processes, and teamwork. METHODS Investigators developed a 2-scenario in situ simulation-based methodology and(More)