crico_2015_08 There is a tangible benefit when hospitals encourage and support staff who report near misses—or good catches. It provides valuable information about systems, processes, and other aspects of patient care that may pose a potential patient risk. This front line information delivers insights which can then lead to organizational changes to mitigate the identified risks. An effective example of this was shared with us by our colleagues at Brigham and Women’s Faulkner Hospital (BWFH).

Following a near miss event, the Interventional Radiology Department at Brigham and Women’s Faulkner Hospital, addressed the risk of medication error when different clear liquids are placed in containers on the sterile field. To eliminate the risk of choosing the wrong clear fluid (even though labeled), they purchased a tinted product that provides a visual cue to differentiate the fluids, thus adding an additional layer of safety.
— Brian McIntosh, RT (R), Director of Radiology, BWFH

We salute the members of the Interventional Radiology department at BWFH who recognized this potential risk to their patients and implemented a simple and effective solution others might find equally helpful.

Related Blog Posts

    SafeCare Study: Inpatient Setting

    The SafeCare Study

    Blog Post
    Results clearly demonstrate a need for better tools, increased measurement of patient harm, and better implementation systems.
    abstract of interconnected people

    Safety Salute: Using Artificial Intelligence to Reduce Missed Diagnoses

    Blog Post
    Through a CRICO grant-funded project, Mitchell Feldman, MD, and Kavishwar Wagholikar, MD, PhD, developed and evaluated a cognitive aid for clinicians to identify patients at risk of a missed or delayed diagnosis.
    1x1_auto_0106

    Telehealth Gone Wrong? Not After These Videos

    Blog Post
    Virtual visits can involve patients calling into their video appointment from the supermarket…fuzzy computer screens during examinations…even doctors “visiting” the wrong patient. These challenges and more present additional clinical and liability risks to busy practices delivering telehealth.
X
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.
Confirm