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When, in 2008, the Joint Commission released its Sentinel Event Alert #38 regarding MRI safety, it joined the ACR's Guidance Document on MR Safe Practices as one of two radiology best-practice documents establishing MR safety protections. However, particularly for MR providers who held both modality-level accreditation from the ACR, and enterprise-level accreditation from the Joint Commission, ...

Software is increasingly making its way into embedded devices in missionand safety-critical domains such as the automotive, avionics or railway industry. Assessing and managing the risk that is inherent in software realizing safety-critical control functions is a key requirement in engineering hybrid systems. This case study reports on a solution carried out to perform fault analysis and critic...

Healthcare delivery settings are complex adaptive and tightly coupled, interrelated systems. Within the larger healthcare system, a key subsystem is the "clinical microsystem" level. It is at this level that clinicians are faced with high levels of uncertainty in their daily work - uncertainty that impacts the quality and safety of care that patients receive. The first aim of this paper is to e...

Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. Brokerage inherent in hospital-to-hospital partnerships can boost relationships between "evidence" and "policy" communities and move developing countries towards evidence based patient safety policy. In particular, we use the experience of a global hospital partne...