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Related Concept Videos

SBAR II: Application of SBAR01:14

SBAR II: Application of SBAR

SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Pharmacovigilance01:19

Pharmacovigilance

Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
This process, termed pharmacovigilance, aims to detect, evaluate, and minimize harmful effects related to medication use. The data collection for pharmacovigilance depends on spontaneous reporting systems, where healthcare professionals or patients voluntarily report suspected ADRs.
In some cases, there...
Cardiopulmonary Resuscitation III: AED Use01:23

Cardiopulmonary Resuscitation III: AED Use

Introduction to AEDAn Automated External Defibrillator (AED) is a portable medical device that analyzes the heart's rhythm and, if necessary, delivers an electrical shock to help the heart re-establish an effective rhythm during sudden cardiac arrest (SCA). SCA occurs when the heart suddenly and unexpectedly stops beating, leading to a loss of blood flow to the brain and other vital organs. In such emergencies, time is of the essence, and using an AED, combined with Cardiopulmonary...

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Enhancing Code Blue, Rapid Response, and Emergency Response Safety in the Veterans Health Administration: Using a

John A Bender, Peter D Mills, Stephen F Kulju

    Joint Commission Journal on Quality and Patient Safety
    |November 29, 2025
    PubMed
    Summary

    Healthcare emergency response systems can fail unexpectedly. A Combined Proactive Risk Assessment (CPRA) identified common failure modes, including equipment and communication issues, to improve patient safety during critical events.

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    Area of Science:

    • Healthcare systems engineering
    • Patient safety research
    • Risk management in medicine

    Background:

    • Medical emergencies require rapid response, but system and equipment failures can impede care.
    • Healthcare professionals may lack awareness of potential system failures during critical events.
    • Deteriorating patient conditions necessitate effective emergency response systems to prevent mortality.

    Purpose of the Study:

    • To investigate failure modes (FMs) in medical emergency response processes using a Combined Proactive Risk Assessment (CPRA).
    • To identify potential solutions and mitigate risks associated with system failures during critical care events.

    Main Methods:

    • A Combined Proactive Risk Assessment (CPRA) approach was employed.
    • Reviewed proactive risk assessments (PRAs) from 13 Veterans Health Administration (VHA) hospitals.
    • Analyzed reactive risk assessments (RRAs), including patient safety reports and root cause analyses, from 172 hospitals.

    Main Results:

    • 1,149 failure modes (FMs) were identified across emergency response processes.
    • Failures commonly occurred during initial patient evaluation (15.4%), code team activation (15.1%), and response (13.5%).
    • Major contributors to FMs included disrupted safeguards (47.6%), equipment issues (22.5%), and communication failures (14.5%).

    Conclusions:

    • The CPRA method offers a comprehensive analysis of risks in emergency response.
    • Identified failure modes and potential solutions can enhance patient safety and mitigate harm.