Patient Safety Alert 2: The Risks of Programmable Medical Equipment (PDF)
The AMC PSO has identified a broad array of programmable medical devices and made several recommendations to decrease risk due to user fallibility, equipment complexity, and highly variable processes.
Strategies and Tactics
A multidisciplinary group examined this event and made several recommendations for machine safety:
- Modify machine checks to include evaluation of default settings with each circuit change to ensure that settings are checked before every new patient case
More AMC PSO Content
Publications such as whitepapers and guidelines derived from the AMC PSO convenings.
Risks Associated with Interventional Procedures in the Ambulatory Setting
Patient Safety Alert Issue 7: The AMC PSO has identified a series of practices employed to address the factors that can contribute to risks associated with interventional procedures in the ambulatory setting.
Missed and Delayed Diagnoses in the ED
Patient Safety Alert Issue 18: The AMC PSO has recently convened Emergency Medicine Leaders to discuss patient safety issues relevant to the Emergency Department setting, yielding both an in-depth analysis of patient safety issues as well as a look at emerging technologies and new strategies to complement existing patient safety protocols.
Diagnosis and Treatment of Ischemic Stroke
Patient Safety Alert Issue 20: The AMC PSO has recently convened subject matter experts and ED clinical leaders to address challenges in assessing and treating patients presenting with symptoms related to ischemic stroke, and, in particular, vertebrobasilar stroke.
Results Management Report
Patient Safety Alert Issue 21: Continuing deliberations on test results management begun in 2013, the Academic Medical Center Patient Safety Organization (AMC PSO) gathered a panel of ambulatory risk management and patient safety experts to address this persistent issue. Related literature shows that 25% of all outpatient medical errors can be attributed to the test-results follow up process.
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