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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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Liquids on floors represent the biggest risk for falls in health care facilities, but risk managers often overlook the need to assess the fall risk of a particular area with wet surfaces, not dry ones, says an expert.
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Five years after the landmark Institute of Medicine report, To Err is Human: Building a Safer Health System, not enough is being done to address medication errors, warns the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, PA.
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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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Low back pain is a frequent patient complaint in the emergency department. In fact, the same patients may visit the ED repetitively with the same complaint. It is easy to be assuaged into thinking that these patients are merely seeking drugs, but to make that assumption can lead a clinician to miss the cauda equina syndrome and may result in a malpractice action if efforts are not taken to identify any new symptoms and signs in a patient with low back pain. This issue provides the reader with a solid understanding of diagnosing and caring for patients with cauda equina syndrome in the ED and the medicolegal issues that arise from failing to diagnose and appropriately treat these patients.
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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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Youre all on the same team right? At times it doesnt seem so. Sometimes, the way people look at the IRB process and its documentation is that its just one more hurdle they have to jump through in order to conduct their research, says Sarah Frankel, PhD, education specialist at the Human Studies Committee of Washington University School of Medicine in St. Louis.
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The Public Access Defibrillation (PAD) trial experience offers clinical trial administrators a firsthand look at how to conduct extensive public education in the absence of individual informed consent.