Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

Michael Ibrahim; Wilson Y Szeto; Jacob Gutsche; Steve Weiss; Joseph Bavaria; Stephanie Ottemiller; Matthew Williams; Jo Fante Gallagher; Neil O. Fishman; Regina Cunningham; Luann Brady; Patrick J Brennan; Michael Acker

Commentary

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114(3):626-635.

View more articles from the same authors.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Mortality due to hospital-acquired infection after cardiac surgery.

June 1, 2022

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery.

January 18, 2023

Association of overlapping cardiac surgery with short-term patient outcomes.

March 3, 2020

Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management.

September 16, 2009

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

System factors affecting patient safety in the OR: an analysis of safety threats and resiliency.

August 25, 2021

The physiology of failure: identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

September 7, 2022

Trial and error: learning from malpractice claims in childhood surgery.

August 24, 2022

Dual surgeon operating to improve patient safety.

September 29, 2021

Fast tracking in cardiac surgery: is it safe?

May 11, 2022

Crisis recovery in surgery: error management and problem solving in safety-critical situations.

September 14, 2022

Errors in surgery: a case control study.

December 14, 2022

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

February 1, 2023

The second victim of unanticipated adverse events.

December 14, 2022

Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture.

September 2, 2020

Crisis preparedness: a systems-based framework for avoiding harm in surgery.

November 30, 2022

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

December 7, 2022

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

August 17, 2022

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

May 4, 2011

The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19.

February 17, 2021

Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety.

June 9, 2021

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

December 1, 2021

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

December 15, 2021

Surgical fire in the United States: 2000-2020.

March 15, 2023

Can a targeted educational approach improve situational awareness in paramedicine during 911 emergency calls?

June 8, 2022

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

September 29, 2021

Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review.

March 10, 2021

Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?

September 1, 2021

Simulating for quality: a centralized quality improvement and patient safety simulation curriculum for residents and fellows.

June 1, 2022

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

Increasing physician reporting of diagnostic learning opportunities.

December 23, 2020

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients.

March 24, 2021

The Collective Leadership for Safety Culture (Co-Lead) team intervention to promote teamwork and patient safety.

February 17, 2021

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

Race and socioeconomic bias in pediatric cardiac transplantation.

February 8, 2023

Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.

August 10, 2022

20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety.

January 26, 2022

Identification of common themes from never events data published by NHS England.

April 14, 2021

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

March 22, 2023

Leveraging a safety event management system to improve organizational learning and safety culture.

March 30, 2022

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis.

March 16, 2022

Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences.

September 22, 2021

Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.

March 2, 2022

The impact of introducing automated dispensing cabinets, barcode medication administration, and closed-loop electronic medication management systems on work processes and safety of controlled medications in hospitals: a systematic review.

April 7, 2021

Psychological safety in intensive care unit rounding teams.

July 21, 2021

Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system.

March 23, 2022

A novel study of situational awareness among out-of-hospital providers during an online clinical simulation.

October 5, 2022

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

May 12, 2021

The effect of race and sex on physicians' recommendations for cardiac catheterization.

July 15, 2002

Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators,

October 7, 2020

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

Association between operative autonomy of surgical residents and patient outcomes.

March 23, 2022

Addressing mistreatment of providers by patients and family members as a patient safety event.

February 16, 2022

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

Diagnostic error in pediatrics: a narrative review.

March 23, 2022

When safety event reporting is seen as punitive: "I've been PSN-ed!"

September 9, 2020

The evidence base for US joint commission hospital accreditation standards: cross sectional study.

July 13, 2022

Implicit racial bias in pediatric orthopaedic surgery.

June 15, 2022

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

Gender bias in risk management reports involving physicians in training - a retrospective qualitative study.

November 9, 2022

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994.

March 6, 2005

To err is human, but what happens when surgeons err?

September 28, 2022

Effect of communication errors during calls to an antimicrobial stewardship program.

March 26, 2008

Impact of staff turnover during cardiac surgical procedures.

February 12, 2020

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

August 31, 2022

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

February 3, 2021

September 15, 2021

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

January 11, 2023

Emergency department monitor alarms rarely change clinical management: an observational study.

September 16, 2020

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

March 24, 2021

Modifications to medical emergency team activation criteria and implications for patient safety: a point prevalence study.

March 24, 2021

State medical board regulation of compounding in physician offices.

June 9, 2021

Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.

August 11, 2021

Diagnostic errors, health disparities, and artificial intelligence: a combination for health or harm.

September 1, 2021

A systematic review of interventions used to enhance implementation of and compliance with the World Health Organization surgical safety checklist in adult surgery.

October 6, 2021

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

July 13, 2022

Interventions and measurements of highly reliable/resilient organization implementations: a literature review.

October 28, 2020

Patient safety culture as a space of social struggle: understanding infection prevention practice and patient safety culture within hospital isolation settings - a qualitative study.

December 14, 2022

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

Implementation of an online reporting system to identify unprofessional behaviors and mistreatment directed at trainees at an academic medical center.

December 21, 2022

Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study.

March 9, 2022

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

July 6, 2022

Pediatric surgical errors: a systematic scoping review.

July 20, 2022

Are you surgically current? Lessons from aviation for returning to non-urgent surgery following COVID-19.

July 22, 2020

Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.

December 8, 2021

The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: a systematic review.

March 29, 2023

Cognitive biases in surgery: systematic review.

March 1, 2023

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

Patient, surgeon, and health care worker safety during the COVID-19 pandemic.

November 3, 2021

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

November 2, 2022

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality.

August 3, 2022

An e-Delphi study to obtain expert consensus on the level of risk associated with preventable e-prescribing events.

April 13, 2022

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

Related Resources

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

September 20, 2023

Inside the preventable deaths that happened within a prominent transplant center.

June 28, 2023

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

April 12, 2023

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Crisis in the Lakeshore Hospital ER.

March 8, 2023

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

October 5, 2022

When medical error becomes personal, activism becomes painful.

September 28, 2022

A health system that won't learn from its mistakes.

September 21, 2022

Hospitals will still have to share safety data publicly—CMS will publish scorecard of avoidable patient harm after all.

August 17, 2022

Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality.

August 3, 2022

The evidence base for US joint commission hospital accreditation standards: cross sectional study.

July 13, 2022

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

June 29, 2022

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

June 1, 2022

Fast tracking in cardiac surgery: is it safe?

May 11, 2022

Patient Safety Innovations

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

April 7, 2022

Failure to rescue following emergency surgery: a FRAM analysis of the management of the deteriorating patient.

February 2, 2022

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

December 15, 2021

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

November 17, 2021

Critical care simulation education program during the COVID-19 pandemic.

November 10, 2021

A theoretical model of flow disruptions for the anesthesia team during cardiovascular surgery.

September 22, 2021

Ripped apart: medical misdiagnosis and malpractice.

August 18, 2021

Rates of serious surgical errors in California and plans to prevent recurrence.

May 19, 2021

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

May 19, 2021

Addiction treatment providers in Pa. face little state scrutiny despite harm to clients.

May 12, 2021

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

‘You’re going to release him when he was hurting himself?’

October 7, 2020

How the pandemic defeated America.

August 19, 2020

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

What constitutes effective team communication after an error?

May 27, 2020

See More About The Topic

Hospitals

Intensive Care Units

Operating Room

Health Care Executives and Administrators

Quality and Safety Professionals

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

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