Accidental decannulation: systems thinking, patient protection, and affordable care.
نویسندگان
چکیده
The principal conclusion of the 1999 Institute of Medicine report “To Err is Human“ is that the major cause of adverse events, rather than being negligent individuals, is actually the result of poorly designed systems.1 A major and foundational implication of this and all subsequent Institute of Medicine reports pertaining to healthcare transformation is that healthcare providers (physicians, nurses, therapists, etc) need to work together in teams in a well designed, integrated delivery system to prevent harm.2
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BACKGROUND Accidental decannulation is a cause of substantial morbidity and mortality in patients in long-term acute care hospitals who require a tracheostomy tube. OBJECTIVE To analyze features of accidental decannulation (AD) following placement of a tracheostomy tube, and to implement strategies to reduce the problem. METHODS An analysis of data collected prospectively for quality manage...
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ورودعنوان ژورنال:
- Respiratory care
دوره 57 12 شماره
صفحات -
تاریخ انتشار 2012