Safety culture and care: a program to prevent surgical errors.

Maureen White Hemingway; Catherine O'Malley; Sandra Silvestri

Commentary

Safety culture and care: a program to prevent surgical errors.

May 13, 2015

Hemingway MW, O'Malley C, Silvestri S. AORN J. 2015;101(4):404-12; quiz 413-5.

View more articles from the same authors.

This commentary describes the development and implementation of a process designed to enhance safety culture in a perioperative services department. The effort employed incident reporting and adverse event review and improved staff comfort with speaking up about potential safety hazards.

PubMed citation

Available at

Related Resources From the Same Author(s)

A protocol for the safe use of hazardous drugs in the OR.

March 25, 2020

Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse specialist.

July 25, 2007

Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review.

November 8, 2023

Systematic review of patient safety interventions in dentistry.

December 9, 2015

The relationship of self-report of quality to practice size and health information technology.

October 10, 2012

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

December 22, 2010

Relationship between quality of care and negligence litigation in nursing homes.

April 13, 2011

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

October 28, 2009

State legal restrictions and prescription-opioid use among disabled adults.

July 20, 2016

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

April 14, 2021

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

August 6, 2008

Errors in the MRI evaluation of musculoskeletal tumors and tumorlike lesions.

August 15, 2007

Impact of staff turnover during cardiac surgical procedures.

February 12, 2020

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

May 22, 2013

How safe is prehospital care? A systematic review.

November 17, 2021

Measurement and monitoring patient safety in prehospital care: a systematic review.

February 24, 2021

Improving the discharge process by embedding a discharge facilitator in a resident team.

November 16, 2011

Diagnostic concordance among pathologists interpreting breast biopsy specimens.

March 25, 2015

Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups.

October 13, 2021

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Going blank: factors contributing to interruptions to nurses' work and related outcomes.

December 1, 2010

How well do health professionals interpret diagnostic information? A systematic review.

August 12, 2015

Understanding the role of non-technical skills in patient safety.

April 25, 2012

The Caregiver Advise, Record, Enable (CARE) act.

May 1, 2018

Death by handwriting.

November 2, 2005

The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.

February 3, 2016

Professionalism lapses and adverse childhood experiences: reflections from the island of last resort.

August 14, 2019

Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture.

January 31, 2007

Implementing electronic health record default settings to reduce opioid overprescribing: a pilot study.

February 28, 2018

Physician health and wellbeing provide challenges to patient safety and outcome quality across the careerspan.

April 13, 2016

Error reporting and disclosure systems: views from hospital leaders.

April 3, 2005

CE: nursing's evolving role in patient safety.

March 15, 2017

Errors and analysis of errors.

December 17, 2008

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

"Managing up" can improve teamwork in the OR.

May 26, 2010

Medication error prevention in the school setting: a closer look.

October 19, 2011

Effective healthcare teams require effective team members: defining teamwork competencies.

February 21, 2007

A salutary tale of mistaken identity in testicular cancer.

September 27, 2006

Accidental iatrogenic pneumothorax in hospitalized patients.

March 15, 2006

The frequency of diagnostic errors in radiologic reports depends on the patient's age.

October 13, 2010

Themed Issue on Innovations in Medication Safety.

August 22, 2018

Impact of senior clinical review on patient disposition from the emergency department.

April 28, 2010

Frequency of medication administration timing error in hospitals: a systematic review.

March 29, 2023

Use of in-situ simulation to investigate latent safety threats prior to opening a new emergency department.

August 19, 2015

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not?

July 23, 2008

The emotional fallout from the culture of blame and shame.

October 18, 2017

Improving the accuracy of patient identification in the medication-use process.

February 8, 2006

Complications in surgery: root cause analysis and preventive measures.

July 11, 2012

Improving hospital performance: culture change is not the answer.

May 4, 2005

Designing highly reliable adverse-event detection systems to predict subsequent claims.

May 6, 2015

Multidisciplinary approaches to reducing error and risk in a patient care setting.

March 6, 2005

Medical errors: where are we now?

November 15, 2006

Using an automated risk assessment report to identify patients at risk for clinical deterioration.

September 12, 2007

Building a culture of safety through team training and engagement.

February 6, 2013

The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project.

April 13, 2022

John M. Eisenberg Patient Safety Awards. The Leapfrog Group for Patient Safety: rewarding higher standards.

March 6, 2005

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

August 18, 2010

The role of documents and documentation in communication failure across the perioperative pathway. A literature review.

January 30, 2005

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

March 15, 2017

Failures in communication through documents and documentation across the perioperative pathway.

May 20, 2015

The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice.

August 7, 2013

High-fidelity simulation’s impact on clinical reasoning and patient safety: a scoping review.

March 29, 2023

Patient safety in inpatient psychiatry: a remaining frontier for health policy.

January 9, 2019

Evaluating a new rapid response team: NP-led versus intensivist-led comparisons.

February 29, 2012

Adverse event reporting priorities: an integrative review.

June 29, 2022

Patients' perceptions of safety if interpersonal continuity of care were to be disrupted.

March 11, 2009

Patient safety and telephone medicine: some lessons from closed claim case review.

February 13, 2008

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

May 4, 2022

Impact of initial hospital diagnosis on mortality for acute myocardial infarction: a national cohort study.

September 14, 2016

Prognosis of undiagnosed chest pain: linked electronic health record cohort study.

April 19, 2017

Implementing a nurse-shadowing program for first-year medical students to improve interprofessional collaborations on health care teams.

August 22, 2012

New graduate registered nurses: Risk mitigation strategies to ensure safety and successful transition to practice.

August 3, 2022

Developing a patient safety surveillance system to identify adverse events in the intensive care unit.

June 16, 2010

Fall prevention in hospitals: an integrative review.

September 21, 2011

Australian hospital leaders on the provision of safe care: implications for safety I and safety II.

September 29, 2021

Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies.

August 22, 2007

Adverse drug event reporting in intensive care units: a survey of current practices.

August 2, 2006

A scholarly pathway in quality improvement and patient safety.

July 1, 2015

Adverse events: root causes and latent factors.

February 15, 2012

Tenfold medication errors: 5 years' experience at a university-affiliated pediatric hospital.

July 18, 2012

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Nurse staffing in hospitals: is there a business case for quality?

January 25, 2006

Nurse-staffing levels and the quality of care in hospitals.

April 3, 2005

Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care.

June 22, 2016

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients.

January 27, 2016

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study.

August 3, 2022

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes.

August 3, 2022

Nursing guidelines for comprehensive harm prevention strategies for adult patients in acute hospitals: an integrative review and synthesis.

February 23, 2022

Errors in drug computations during newborn intensive care.

March 27, 2005

A literature review of the individual and systems factors that contribute to medication errors in nursing practice.

September 16, 2009

Learning from incidents in healthcare: the journey, not the arrival, matters.

April 27, 2016

SWITCH for safety: perioperative hand-off tools.

November 6, 2013

Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.

February 12, 2014

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review.

December 1, 2021

Missed diagnosis of critical congenital heart disease.

October 22, 2008

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.

March 18, 2015

Related Resources

Perspective

Patient Safety in Office-Based Care Settings

January 31, 2024

Interview

In Conversation with...Richard Ricciardi about Office-Based Patient Safety

January 31, 2024

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: User Database Report.

January 14, 2024

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

June 28, 2023

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

April 27, 2023 - April 27, 2023

Ambulatory Surgery Center Survey on Patient Safety Culture.

May 29, 2023

Proactive patient safety: focusing on what goes right in the perioperative environment.

May 24, 2023

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety.

January 26, 2022

Honesty and transparency, indispensable to the clinical mission--Parts I-III.

December 15, 2021

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

November 24, 2021

"It's a big part of being good surgeons": surgical trainees' perceptions of error recovery in the operating room.

July 28, 2021

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

Surgical patient safety officers in the United States: negotiating contradictions between compliance and workplace transformation.

February 24, 2021

The Anesthesia Patient Safety Foundation Stoelting Conference 2019: perioperative deterioration--early recognition, rapid intervention, and the end of failure-to-rescue.

November 11, 2020

Better care for surgical patients: recognizing and responding to the unexpected to save lives.

January 29, 2020

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.

June 12, 2019

Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative.

May 15, 2019

Identifying quality markers of a safe surgical ward: an interview study of patients, clinical staff, and administrators.

May 2, 2018

Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.

March 7, 2018

Safety culture in the operating room: variability among perioperative healthcare workers.

September 13, 2017

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

August 16, 2017

Cutting-edge efforts in surgical patient safety.

June 14, 2017

Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data.

March 29, 2017

The impact of major intraoperative adverse events on hospital readmissions.

August 17, 2016

Promoting patient safety with perioperative hand-off communication.

August 10, 2016

Health information technologies: from hazardous to the dark side.

August 3, 2016

Perioperative safety: learning, not taking, from aviation.

July 27, 2016

See More About The Topic

Operating Room

Health Care Executives and Administrators

Surgery

Surgical Complications

Epidemiology of Errors and Adverse Events

Safety culture and care: a program to prevent surgical errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Safety culture and care: a program to prevent surgical errors.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site