Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ proc... AHRQ Patient Safety

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.
Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

Failure mode and effects analysis was used to identify vulnerable handoff and communication processes in organ procurement and transplantation. A communication error led to the widely publicized death of a lung transplant patient at Duke University Medical Center in 2003.

abrir aquí para acceder al documento AHRQ:
AHRQ Patient Safety Network

o bien abrir aquí para acceder al documento PDF de 8 páginas:
http://www.natco1.org/members/documents/Steinberger9_09Test.pdf