Victor R. Klein

TeamSTEPPS and patient safety in healthcare

Communication problems in healthcare are considered to be a leading cause of medical errors and often the root cause of sentinel events. This article will review the implementation of TeamSTEPPS in the two large health systems. The challenges in the implementation process, the successes, failures, and the obstacles will be discussed. Comparisons between the systems as well as lessons learned after implementation will be reviewed to enable hospitals and health systems to implement and sustain a successful TeamSTEPPS program.

Myocardial ischemia: A complication of r ritodrine tocolysis

Demonstration of leakage of fetal blood into the maternal circulation secondary to damage in the placental barrier, as demonstrated in the above case reports, may have additional importance in the Rh-negative woman. Further studies will show if Rh-negative women with similar conditions should receive Rho (D antigen) immune globulin as is presently done in Rh-negative women undergoing ilmniocentesis.

Fetal distress during a maternal systemic allergic reaction

&NA; Systemic allergic reactions to food ingestion rarely result in life‐threatening situations. When these reactions occur during pregnancy, however, the accompanying physiologic changes may result in fetal distress. A case of repetitive late decelerations in the fetal heart rate during a maternal allergic reaction is presented. Prompt and aggressive medical management brought about total resolution of maternal and fetal compromise. (Obstet Gynecol 64:15S, 1984)

A new frontier in healthcare risk management: Working to reduce avoidable patient suffering

This article presents a new avenue for healthcare risk managers to drive improvement for patients and healthcare organizations alike: working to reduce avoidable patient suffering. It briefly describes the problem of patient suffering, differentiates between avoidable and unavoidable suffering, and suggests that common risk management tools can be used to tackle the problem. It also highlights a success story from one large health system.

The Bland-White-Garland syndrome in pregnancy

both cases on initial study. Later, the lateral ventricle width/hemispheric width ratio was greater than the normal range even for 15 to 17 weeks (Fig. 2). Early in development of the fetal brain, the aqueduct which separates the third and fourth ventricles is relatively short and broad. With growth and differentiation of the caudal mesencephalon, the aqueduct becomes greatly elongated and narrowed. This normal constriction of the aqueduct occurs rapidly between the fifteenth week and the seventeenth week after conception. This corresponds to the seventeenth to nineteenth week after the last normal menstrual period, the time at which hydrocephalus apparently developed in these two fetuses. Therefore, it is reasonable to suggest that congenital hydrocephalus due to X-linked aqueductal stenosis may develop as an exaggeration of the normal process of narrowing of the aqueduct of Sylvius which occurs during growth of the caudal mesencephalon 15 to 17 weeks after conception.

Pearls of wisdom: Practical application of the Pearls series

Scores of ASHRM members have collaborated to produce the Pearls Series, a set of pocket guides on topics of interest for not only risk managers but also administrators, clinicians, and board members. The succinct format facilitates the dissemination of pertinent information to a wide audience. Risk managers should be knowledgeable of the Pearls topics, understand how to develop appropriate metrics, and manage the monitoring and performance improvement aspects that are critical to ensuring successful knowledge transfer.