A Framework for the Analysis of Communication Errors in Health Care.

Objectives: The goal of this study was to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. We aimed to develop a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Methods: This observational study used the Delphi method to develop a taxonomy code sheet for identifying communication errors reported in the Veterans Health Administration patient safety databases between April 2018 and March 2021.

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration.

Objectives: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy.

Methods: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff.

Silicon Quantum Dot-Polymer Fabry-Pérot Resonators with Narrowed and Tunable Emissions.

Luminescent silicon nanoparticles have been widely recognized as an alternative for metal-based quantum dots (QDs) for optoelectronics partly because of the high abundance and biocompatibility of silicon. To date, the broad photoluminescence line width (often >100 nm) of silicon QDs has been a hurdle to achieving competitive spectral purity and incorporating them into light-emitting devices. Herein we report fabrication and testing of straightforward configuration of Fabry-Pérot resonators that incorporates a thin layer of SiQD-polymer hybrid/blend between two reflective silver mirrors; remarkably these devices exhibit up-to-14-fold narrowing of SiQD emission and achieve a spectral bandwidth as narrow as ca.

Cardiac Telemetry Downtime and Contingency Plan Development: A Review of Downtime Events Reported in the Veterans Health Administration.

Background: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety.

Problem: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime.

Approach: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020.