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Engaging Patients and Families in Root Cause Analysis of Sentinel Healthcare Events: The Story of Justin Micalizzi PDF Print E-mail



Working with two patient advocates, the Reliability Center has released a webcast that analyzes the sudden, unexpected death in January 2001 of 11-year-old Justin Micalizzi immediately following surgery for an infected ankle. For 10 years, the Micalizzi family—especially his mother, Dale, now a well known patient safety advocate—sought unsuccessfully and without the cooperation of the hospital to discover what caused Justin’s death or at least to elicit a clear and honest pledge that the hospital would commit sincerely to understanding what had happened.

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The Risk of Workarounds PDF Print E-mail


In April, Patient Safety and Quality Healthcare published an article summarizing a recent webinar presented through ourCenter for Safety and Clinical Excellence. The article is titled “Smart Pump Workarounds – What’s the Legal Risk?”, and it focuses on personal accountability on the part of caregivers in safely operating Smart IV pumps.

Caregiver accountability has been a hot topic in recent months. As it relates to IV medication safety, it’s a critical issue and worth paying attention to. It’s been shown that clinicians often implement process workarounds, including not utilizing the drug library, overriding soft dose and concentration alerts, reprogramming infusions as rate in ml/hr following hard limits, and occasionally removing IV tubing from pumps and delivering medication boluses by gravity to avoid a high dose alert.

Last Updated on Monday, 07 May 2012 10:58
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