Qual Saf Health Care
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Qual Saf Health Care · Sep 2002
Unexpected cardiac arrest among children during surgery, a North American registry to elucidate the incidence and causes of anesthesia related cardiac arrest.
Relatively rare adverse events, such as unexpected cardiac arrest, are difficult to study in the clinical setting. These events are often unpredictable in their occurrence (prompting interest in their investigation) and do not occur with sufficient frequency in any single institution to provide an adequate sample for analysis. ⋯ This approach was adopted for investigation of cardiac arrest in children when it became apparent from analysis of malpractice claims that a significant clinical problem existed. This report provides a brief historical account of the development of the Pediatric Peri-Operative Cardiac Arrest (POCA) Registry and elaborates on the methodology including strengths, weaknesses, and practical implementation issues.
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Qual Saf Health Care · Jun 2002
Value of a cognitive simulation in medicine: towards optimizing decision making performance of healthcare personnel.
Medical errors can be reduced or avoided by training in both factual knowledge and in optimal information processing. The latter is of special importance when task settings are complex, when information about a patient's condition is ambiguous and uncertain, and when rapid changes can occur. ⋯ The strategic management simulation (SMS) has been used worldwide with many high level professionals. Its application to assessing and training medical decision makers is discussed.
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Qual Saf Health Care · Jun 2002
The need for risk management to evolve to assure a culture of safety.
There is a need for the traditional risk management model, which focuses on department based risk assessment, loss management and risk financing, to evolve to enable it to become more responsive to the increasing demands for safety and accountability imposed on the current US healthcare system. The risk management focus must become more strategic and systems based, and less crisis orientated and individual provider based, in order to provide its greatest value to the organization and the patients those organizations serve.