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This case involves several issues related to standard of care and possibly to causation, which are subject to review by the facilitys risk manager.
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In the aftermath of a tragic sentinel event traced back to poor processes, the appointment of a new patient safety officer at Duke University Hospital System in Durham, NC, raises several immediate questions.
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The 2003 transplant error at Duke University Hospital in Durham, NC, that led to the appointment of a new patient safety officer at Duke University Hospital System in Durham, NC, was traced to a lack of redundancy in the system that ensured donor organs matched the patient.
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Two hospitals in Colorado were accused of harvesting a mans organs before he was declared dead. The coroner actually ruled the death a homicide, saying the cause was removal of his internal organs by an organ recovery team. The only trouble with the story? The coroners conclusions were wrong, according to everyone involved except the coroner himself.
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If your nurses are so uncomfortable with the quality of the informed consent process that they dont want to sign as a witness, you should consider that a red flag that you have some serious work to do.
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If terrorists want to acquire radioactive materials in your facility, they may not do it by breaking in to the oncology department in the middle of the night. They might just pay a technician to steal the material for them, says a retired FBI agent.
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One of the best ways to thwart any attempt at stealing nuclear materials from your facility is to take seriously any report of missing material, says the president of the International Association for Healthcare Security and Safety in Glendale Heights, IL.
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A terrifying failure during general anesthesia, once thought to be so rare that it did not warrant much attention, actually is common enough that risk managers should launch a specific, focused effort at reducing the problem, known as anesthesia awareness.
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In response to the national shortage of vaccine, Thomson American Health Consultants has developed an influenza sourcebook to ensure you and your hospital are prepared for what you may face this flu season.
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Anesthesia awareness is not just a problem for the anesthesia department. That was a key message of JCAHO when it issued its recent Sentinel Event Alert on the issue.