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April 2015
Perspectives on Safety icon
Perspectives on Safety
Surgical Checklists
INTERVIEW
In Conversation With… Lucian Leape, MD
A pioneer in patient safety, Dr. Leape is Adjunct Professor of Health Policy at the Harvard School of Public Health and Chairman of the Lucian Leape Institute of the National Patient Safety Foundation. His groundbreaking research has focused on patient safety and quality of care. We spoke with him about checklists and the field of patient safety.
(.MP3 | 12.2 MB)
INTERVIEW
In Conversation With… David Urbach, MD, MSc
Dr. Urbach is Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto. We spoke with him about his study evaluating the effectiveness of checklists in Ontario, Canada and its implications for a variety of safety interventions.
(.MP3 | 9.39 MB)
Cases & Commentaries
SPOTLIGHT CASE
A woman admitted to the hospital with a presumed transient ischemic attack and possible gastrointestinal bleeding was found unconscious and in cardiac arrest on hospital day 2. Despite maximal resuscitation efforts, the patient died. Autopsy revealed that the cause of death was an acute aortic dissection.
Commentary by Shirley Beng Suat Ooi, MBBS (S'pore)
CME/CEU credit available for this case

For a man with hypertension, prostate cancer, and chronic kidney disease hospitalized with acute kidney injury, discharge planning created numerous challenges. The inpatient team wanted a 1-week follow up, but the patient was new to this health system and had not yet seen a primary care provider. With the next available appointment in 6 weeks, the patient was instructed to call the urgent care clinic (which offered only same-day appointments) 1 week later. However, he never made it to the clinic and presented to the emergency department 2 weeks later with poorly controlled hypertension.
Commentary by Timothy W. Farrell, MD

During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
Commentary by Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH
Photograph of doctor using a computer
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