Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation. | PSNet

Provide Feedback |

Register

Study

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

October 28, 2009

Steinberger DM, Douglas S, Kirschbaum MS. Prog Transplant. 2009;19(3):208-14; quiz 215.

View more articles from the same authors.

Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.

PubMed citation

Free full text (PDF)

Related Resources From the Same Author(s)

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

August 4, 2021

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

December 12, 2012

A Department of Medicine infrastructure for patient safety and clinical quality improvement.

August 8, 2018

Advancing the science of patient safety.

September 20, 2011

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Evidence-based guidelines for fatigue risk management in emergency medical services.

March 14, 2018

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Teaching quality improvement.

September 22, 2010

View More

Related Resources

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

September 29, 2017

Interruptions and miscommunications in surgery: an observational study.

September 24, 2016

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

May 19, 2015

A systematic quantitative assessment of risks associated with poor communication in surgical care.

December 21, 2014

Deconstructing intraoperative communication failures.

October 19, 2012

A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.

June 1, 2012

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

May 11, 2011

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.

March 23, 2011

Communication failure in the operating room.

March 3, 2011

View More

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Discontinuities, Gaps, and Hand-Off Problems

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364